Leqembi IQLIK and Medicare: Everything You Need to Know Before You Switch
QLIK and Medicare Choices
For those of you who are not familiar with IQLIK, let me explain. After Eisai successfully launched Leqembi in July 2023 using a clinically administered infusion, they realized traveling to infusion centers was a hardship for many patients. Over the next year they developed Leqembi IQLIK as a weekly subcutaneous injection for maintenance therapy after patients complete the initial infusions and a amyloid PET scan shows a plaque free brain. IQLIK was FDA approved in August 2025.
The FDA is expected to give final approval for LEQEMBI IQLIK that would be the first and only anti-amyloid treatment to offer at-home injection options for initiation and maintenance dosing for this progressive, relentless disease. FDA action date is set for September, 2026.
Both IQLIK for initial treatment and for maintenance are considered a drug by Medicare.
This give those of us starting Leqembi or on maintenance a chance to decide if infusion or at-home injections are best for us in our situations.
I recently started on Leqembi maintenance and had to weigh the cost of remaining on infusions paid by Medicare as a treatment under Part B, they pay for 80% of all costs associated with this treatment. Supplemental Medicare insurance may pick part or all of the remaining 20%. Or, switch to IQLIK that is covered by Medicare Part D. Part D is a little complicated initially. Each of us have to weigh our circumstances and the benefits of each option.
All of that leads directly to the next, and often most confusing, piece of the decision: how Medicare Part D actually works in practice. Unlike Part B, where your provider typically handles billing and Medicare pays its share automatically, Part D shifts more responsibility to the patient, the prescribing specialist, and the specialty pharmacy coordinating the drug. Coverage depends on the specific drug plan you’ve chosen, its formulary, and how that plan manages high-cost specialty medications like IQLIK. Understanding this structure is essential, because it determines not only your out-of-pocket costs but also the exact steps required to get the medication approved, dispensed, and delivered.
How do you actually submit an IQLIK prescription to Medicare?
This has been one of the most confusing parts of the process, and for good reason. Submitting an IQLIK prescription (like Leqembi’s IQLIK maintenance dosing) is not like sending a normal prescription to a pharmacy.
So how does it actually work?
If the drug is self-injected at home, it typically falls under Part D. If it’s given in a clinic or infusion center, that’s Part B.
Since IQLIK is a home injection, it goes through your drug plan not directly through Medicare.
Your doctor plays a key role here. They must send the prescription electronically or by fax to a specialty pharmacy (not a regular retail pharmacy like CVS). The prescription needs to include your diagnosis, the dosing schedule, and often supporting documentation.
From there, the specialty pharmacy takes over. They submit the claim to your Part D plan, determine coverage and copay, and identify whether prior authorization is required. For drugs like Leqembi IQLIK, plans want confirmation of early Alzheimer’s or mild cognitive impairment, proof of amyloid (PET scan or CSF), and a prescriber attestation. Your doctor’s office and the pharmacy usually coordinate this together.
If all goes well, your Medicare approved drug plan responds. Your drug plan tells the pharmacy whether IQLIK is in their formulary, the prior authorization required and what your cost-sharing will be. Then you are billed for your portion of the drug cost (copay, coinsurance, or deductible) and any non-covered amount. This will be a pretty hefty amount. They may require payment before shipping, just like pharmacies require you to pay before you get your prescription locally.
At this point, the process can feel very transactional, approval, billing, and payment, all happening quickly and often with significant upfront cost. Naturally, the next question is how those out-of-pocket payments are tracked over time, and when you begin to see financial relief. That’s where the mechanics of Medicare Part D become especially important, particularly the way your spending accumulates toward the annual cap.
How Medicare $2,100 Cap is Tracked
Every time a prescription is filled, the pharmacy (including specialty pharmacies) submits a claim electronically to your Medicare Part D plan. Your spending is tracked cumulatively. Your Part D plan keeps a running total of what you’ve paid. This is called your true out-of-pocket (TrOOP) cost.
Your drug plan insurance company reports data to Centers for Medicare & Medicaid Services, which sets the rules and ensures the cap is applied correctly.
How you can see your progress
You don’t have to guess—your plan keeps you updated:
Explanation of Benefits (EOB) statements (monthly)
Your plan’s website or app (often real-time tracking)
Customer service can tell you your current TrOOP total
What happens when you hit the cap
Once your tracked out-of-pocket spending reaches the limit (about $2,100 starting in 2026): You pay $0 for covered Part D drugs for the rest of the year. No forms. No extra steps. It switches automatically.
Things to check BEFORE Your First Prescription
MEDICARE PART D (DRUG)
You must be currently enrolled in Medicare Part D. Medicare Part D isn’t a card or a separate “government plan” by itself. Part D requires your selection and enrollment in a Medicare Recognized separate Drug Plan Insurance Company. If you are not enrolled in part D, then you will have to pay 100% of all your drug costs.
Ways to Check Part D
While Part B is printed on your social security card, Part D is not. With Medicare, enrolling in Part D (prescription drug coverage) is optional.
· If you enrolled in a Medicare and added an approved private insurance drug plan (e.g., Humana, Blue Shield) at that time, you have Part D.
· If you enrolled in a Medicare Advantage plan (Part C) with drug coverage, you have Part D.
· You might safely skip it if you already have: Employer or retiree drug coverage; VA drug benefits; TRICARE.
· If you enrolled, you should also have either a separate Part D plan ID card issued by your drug plan or a welcome letter or annual notice from the insurance company (like WellCare, AARP, etc.)
· Look at your monthly premiums, check your Social Security statement or bank account. If you see a separate premium for a drug plan, that’s Part D. It may be deducted from your Social Security check, or billed directly by the insurance company.
· You can also log into your Medicare account. Go to the official site: Centers for Medicare & Medicaid Services website (Medicare.gov) Once logged in, look under: “My Plans & Coverage”. It will clearly show whether you have Part D and the name of your drug plan. Call Medicare directly, 1-800-MEDICARE (1-800-633-4227). Ask: “Do I currently have a Part D prescription drug plan?” They can tell you instantly.
How to Enroll in Part D
If you did not enroll in Part D when you first applied for Medicare you can enroll during open enrollment October 15th to December 7th by selecting a drug plan. It will be effective on January 1.
Special Enrollment Period (SEP)
You can enroll outside the fall window if you have a qualifying event, such as: Losing other creditable drug coverage (like employer or VA coverage); Moving out of your plan’s service area; Qualifying for Extra Help (low-income subsidy).
IQLIK MUST BE ON THE DRUG PLAN’S FORMULARY
The specialty pharmacy will deny your prescription if your drug plan does not have IQLIK listed on their formulary. It doesn’t matter if the co-pay is 100%, the drug just has to appear on their list of drugs available to their subscribers.
How to Check Your Drug Plan for IQLIK
Call your drug company and ask if IQLIK is on your plan.
Checking to see if your drug plan covers IQLIK can be challenging. Another method is to check to see if your drug plan covers IQLIK is via medicare.gov. This takes several screens to get to a list of drug plans that include Leqembi IQLIK. I found only 6 drug insurers that had IQLIK in their formulary: Aetna Medical-Silver Script, AARP, Humana Basic Rx, Blue Shield, WellCare and Health Spring. And you have to be careful to select the exact plan number because they all have several slightly different plans.
Open medicare.gov. This is the path I followed:
At the bottom of the first page-Take Action/Find health & drug plans/ zip code/ continue/ Medicare drug plan (Part D)/ Find plans/ I don’t get help from any of these plans/ Continue/ Add prescription drug/ Leqembi/ Leqembi/ Leqembi 360mg/1.8ml solution auto injector/ Frequency/ Every Month/ Quantity/ 4/ Add to my drug list/ confirm drug/ Done adding drugs/ Add up to 5 pharmacies/ check Mail-in pharmacy/ Your Location – zip code/ Find Pharmacies/ (these pharmacies are local and will not have QLIK) / Continue to view plans/ Choose a plan to join/ You don't have to join a plan, this just shows what plans has a IQLIK formulary, their rating and prices.
Hopefully by next September this list will have grown substantially. These drug plans also indicate that IQLIK is being handled by Medicare as a Part D drug.
IQLIK is NOT on Your Drug Plan
You have two options: Stay on infusions and wait until October 15th to change your drug plan so you can start IQLIK on January 1 or ask for an exception.
Exception: If you have a drug plan that does not have IQLIK in its formulary, this may help. Regardless of whether a plan chooses to add a Part-D drug to formulary or not, the prescriber can always request a non-formulary medical exception. Even though the exceptions process is common, some health care providers are not familiar with it. Download this article and take it to your neurologist: (see Exceptions | CMS for more details) or https://www.cms.gov/medicare/appeals-grievances/prescription-drug/exceptions.
Your doctor can also file an exception for other types of denial by your drug plan.
How are Test costs handled by Medicare?
There is one more consideration for those switching to IQLIK maintenance and potentially IQLIK when it replaces infusions: How does Medicare cover the other treatment costs of MRIs, blood tests, and Amyloid PET scans?
Even if the FDA approves IQLIK for initial treatment (replacing IV infusions), Medicare would still need to cover the medically necessary tests that determine whether you can safely start and continue treatment. However, the coverage may come under different parts of Medicare, depending on the test.
Here's how it would likely work:
Test
Expected Medicare Coverage
Amyloid PET scan (or CSF biomarker test)
Yes. This is used to confirm amyloid before starting treatment and is generally covered when medically necessary under current Medicare policies.
Baseline MRI
Yes. A brain MRI is required before starting treatment to assess the risk of ARIA and is considered medically necessary.
Follow-up MRIs
Yes. Medicare currently recognizes that patients receiving anti-amyloid therapy may need periodic MRIs to monitor for ARIA.
Blood tests (CBC, CMP, APOE testing if ordered, etc.)
Generally yes, if your physician orders them as medically necessary. Coverage depends on the specific laboratory test and the reason it is is ordered.
Why I think this is unlikely to change
The drug may move from Part B (infusion) to Part D (self-administered injection), but the MRIs, PET scans, neurologist visits, and laboratory tests are medical services, not prescription drugs.
That means they would generally continue to be billed under Medicare Part B, while the IQLIK prescription itself would be covered under Part D.
So your coverage could look like this:
IQLIK medication → Medicare Part D
Neurologist visits → Medicare Part B
MRI scans → Medicare Part B
Amyloid PET scan → Medicare Part B
Laboratory tests → Medicare Part B, when medically necessary
One thing that is still unknown
If the FDA approves IQLIK for initial dosing, CMS (Medicare) will still need to issue or update its reimbursement guidance. CMS could specify:
exactly which monitoring tests are required,
how often MRIs must be performed,
whether the existing registry requirements remain the same, and
how providers should bill for patients who receive the drug at home.
I would be surprised if Medicare stopped paying for the required diagnostic and safety monitoring, because those tests are essential to the FDA-approved prescribing information and to safe use of the drug.
https://www.medicare.gov/coverage/monoclonal-antibodies-for-treating-early-alzheimers-disease