CMS, Medicare to Cover COVID-19 Antibody Drug in Nursing Homes

The federal government this week announced that Medicare will cover a recently approved antibody treatment for COVID-19 in a range of settings, including nursing homes.

The Food and Drug Administration on Monday cleared on an emergency basis the use of bamlanivimab — a monoclonial antibody infusion — for adults with mild to moderate cases of COVID-19.

Under the terms of the Emergency Use Authorization (EUA), practitioners can only administer the drug in settings where they can also provide immediate treatment for a potential allergic reaction, and activate an emergency medical system.

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The Centers for Medicare & Medicaid Services (CMS) indicated that health providers will likely receive the first shipments of bamlanivimab for free; as a result, Medicare will only cover the cost of the infusion, set at $309.60, and not provide additional payments for doses received free of charge.

The structure is similar to a CMS-Department of Health and Human Services (HHS) plan to direct vaccines to nursing homes in the immediate wake of an EUA. Under that initiative, retail pharmacy giants Walgreens and CVS will receive payments from Medicare to administer vaccinations, with the vaccines themselves already paid for by the federal government.

Should bamlanivimab hit the open market, CMS will set a payment at 95% of average wholesale price.

The coverage, which will last for the duration of the wider federal public health emergency (PHE), will also extend to home health agencies, hospital infusion centers, and vendors that service nursing homes, according to CMS.

“Our timely approach means beneficiaries can receive these potentially life-saving therapies in a range of settings — such as in a doctor’s office, nursing home, infusion centers, as long as safety precautions can be met,” administrator Seema Verma said in a statement. “This aggressive action and innovative approach will undoubtedly save lives.”

Medicaid beneficiaries should also be able to receive covered bamlanivimab treatments — “with limited exceptions” — under the terms of the wider increase in the Federal Medical Assistance Percentage (FMAP) enacted as part of federal coronavirus relief efforts.

“A condition for receipt of this enhanced federal match is that a state or territory must cover COVID-19 testing services and treatments, including vaccines and their administration, specialized equipment, and therapies for Medicaid enrollees without cost sharing,” CMS observed.

The EUA for the treatment specifically restricts its use to coronavirus patients who are at “high risk” of developing severe COVID-19 and requiring subsequent hospitalization. That group that includes those 65 and older, as well as people with body mass indices (BMIs) over 35, diabetes, or chronic kidney disease.

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