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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

Some of Marwan Sabbagh’s patients at the Barrow Neurological Institute in Phoenix have paid for the scan on their own. Another option is a spinal tap. Biogen may even cover the cost of analyzing the test. Yet many people fear the procedure. The neurologist has offered some entry to a clinical trial where the scan and treatment are paid for.

“There are many bottlenecks,” said Sabbagh, who’s been paid to advise Biogen. “It’s not exclusive to our healthcare system.”

Large insurers that haven’t publicly disclosed their positions on Aduhelm and didn’t respond to Bloomberg’s questions include Anthem Inc., CVS Health Corp. and Centene Corp. UnitedHealth Group Inc. referred to comments from July, when the company said it was still evaluating the drug and awaiting guidance from Medicare.

While the government health program is still deciding whether to cover Aduhelm, millions of patients will soon pay either way: Medicare premiums will rise by about $11 per person per month in 2022 to prepare for the potential costs of the drug and similar therapies that may follow.

Other insurers said they would cover Aduhelm in their plans that administer Medicaid, the state-federal health program for low-income people, if required. Molina Healthcare Inc., which has 4.8 million members primarily in Medicaid plans, said Aduhelm would only be covered as called for by states.

The drug isn’t covered in the company’s offerings through the Affordable Care Act marketplace, where individuals and families can buy government-subsidized health plans. Molina hasn’t received any requests for coverage yet, a spokeswoman said.

 

State Medicaid programs are required to cover the drug because Biogen participates in the Medicaid drug rebate program, a spokesperson for the U.S. agency said in an email.

Most insurers that responded to Bloomberg’s questions said they would continue to evaluate new evidence and take Medicare’s decision into account when it comes. As a condition of the drug’s approval, Biogen must do another study to confirm Aduhelm’s benefits. Adding to the turmoil, Biogen said this month that 64-year-old research chief Alfred Sandrock, a key figure behind Aduhelm, will retire at the end of the year.

Meanwhile doctors and patients who want the drug are seeking it through clinical trials or Biogen’s access program. Jonathan Liss, founder of Columbus Memory Center in Georgia, said two of his patients are getting the drug through the company program, and he’s personally covering the costs for a third.

Liss, who has received money from Biogen to serve on advisory boards, said he’s wary of starting patients on the drug who might have to stop if Medicare decides not to cover it.

“What I’ve said to a number of patients is ‘Look, I can get you the drug,’” he said, “‘but I don’t know if it’s going to get paid for.’”

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