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Insurers balk at paying for Biogen's $56,000-a-year Alzheimer's treatment

John Tozzi, Angelica LaVito and Anushree Dave, Bloomberg News on

Published in Health & Fitness

Questions about the drug’s effectiveness have persisted since it wobbled to the U.S. market, with evidence so controversial that three FDA advisers resigned after its June approval. Europe’s regulator has indicated it won’t recommend clearance.

While critics warned that the costly therapy threatened to overwhelm government health programs, sales have been just a trickle, disappointing investors in Biogen and its partner Eisai Co. Biogen’s stock has surfed the drug’s fortunes. The shares neared $415 in June when prospects for use still seemed bright; since then, they’ve dropped by more than a third.

Some patients’ prescriptions are covered. Kaiser Permanente, the giant California-based health maintenance organization, said it pays for the drug when a member’s physician determines it’s medically necessary.

Humana’s decision to cover patients who meet the trial criteria isn’t final, a spokesman said. The Medicare-focused insurer remains concerned about conflicting data on the drug and said the health program’s decision will influence its final policy. Neither company said how many members have received the drug.

Other insurers are more restrictive. In Biogen’s June news release announcing the drug launch, a Cigna Corp. executive was quoted saying that the company was “working to ensure that the patients who will benefit most from this new treatment have a clear path to access it.”

Since then, though, Cigna called the drug “unproven” and won’t cover it, according to its policy. In an emailed statement, the company cited “emerging concerns regarding its safety and efficacy.”

 

At First Choice Neurology, a large chain of clinics in south Florida, about 80 patients are receiving Aduhelm, according to Jeffrey Gelblum, a doctor at the practice. Some commercial insurers are approving claims for the drug, he said, without providing names.

Many patients who haven’t gotten a green light get the drug for free from Biogen at least temporarily while the practice appeals to their insurers, he said, which can take months. Gelblum said that’s problematic for a drug most likely to work early in the disease.

“I don’t want to waste time,” he said in an interview. “You’ve got a two-year window of intervention here, and if a patient comes in saying, ‘Look I’ve had this problem for a year,’ well, now I know I’m already a year into the problem.”

Determining whether patients qualify for treatment can also be a barrier. One way of looking for telltale amyloid plaques is a PET scan of the brain. The procedure costs about $5,000, and insurers won’t pay.

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