Insurers won't pay for Aduhelm until they know it works

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Insurers need more evidence of the clinical benefit of Biogen's controversial Alzheimer's drug Aduhelm before they start paying for it, Bloomberg reported Nov. 18.

Bloomberg surveyed 25 of the nation's largest insurers, and none of them deemed the drug "medically necessary." Most indicated they view the drug as experimental and said they needed to see more evidence on the drug's ability to slow cognitive decline.

The question of whether insurers will cover the drug is colored not only by the pharmaceutical and medical communities' intense debate over whether it works but also its high list price. Aduhelm, which is administered based on a patient's weight, costs $56,000 a year for a 163- pound patient.

Several health systems and insurers recently indicated they would not cover or offer Aduhelm, a list that includes the Department of Veterans Affairs, Cleveland Clinic, New York City-based Mount Sinai, Boston-based Mass General Brigham and eight Blue Cross Blue Shield affiliates. Notably, Humana said it will cover Aduhelm for members who resemble patients Biogen claimed were helped by the drug in clinical trials. 

Medicare won't decide its final policy for the drug until April. When CMS announced Medicare Part B premiums and deductibles would see the largest hike in the program's history next year, however, the agency said one of the key reasons is the potential need to cover the high cost of Aduhelm. 

Paul Schulz, MD, a neurologist at Memorial Hermann-Texas Medical Center in Houston who is treating about half a dozen people with Aduhelm, told Bloomberg that healthcare staff can spend five hours trying to secure the drug's approval from insurers, which is rarely granted. Dr. Schulz has received fees from Biogen for giving speeches.

Biogen did not respond to Bloomberg's requests for comment.

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