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

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    A US health insurance company says more evidence is needed before paying Biogen Inc.’s Aduhelm.

    All of the 25 major insurance companies that responded to the Bloomberg News survey “medically need” $ 56,000 a year, a term used to describe treatments that are needed for a particular illness and meet medical standards. I didn’t judge. Most people consider aducanumab experimental, but others still value it.

    Insurers have cited uncertainty about the benefits and side effects of refusal.Still, Humana Inc., the second largest Medicare insurance company in the United States, covers medicine for members similar to the members it backed up. Clinical trials..

    With a health insurance company Government program Despite clinical trial results that are inconsistent with the opposition from scientific advisors, it plays a huge role as a gatekeeper for aducanumab approved by the Food and Drug Administration. Some patients pay for treatment at their own expense or ask for free supplies, but doctors who want to prescribe medication must work hard to justify it.

    Paul Schulz, a doctor at McGovern Medical School and Memorial Hermann-Texas Medical Center at UT Health Houston, said staff could spend five hours getting approval from the insurance company for each person who was considered eligible for Aduhelm. It is rarely allowed.

    “It’s very difficult to spend so much time getting something approved on a case-by-case basis,” said Schultz, who is treating about half a dozen people with aducanumab. He received a fee from Biogen to give a speech.

    Targeting 63 million elderly or disabled Americans, Medicare has already raised premiums in anticipation of demand, but will not set Aduhelm’s final policy until April. Private insurance companies say they need more evidence that treatment actually slows the rate at which patients with Alzheimer’s disease get worse.

    A representative from Healthcare Services said in an email that aducanumab is not medically needed to treat Alzheimer’s disease “because clinical benefits have not been established.” The company has approximately 17 million members in the Blue Cross Blue Shield program in five states, including Texas.

    Biogen did not respond to requests for comment on this story.

    Doctors, patients and families are anxious for relief from about 6 million Americans, most of whom are memory-depriving Alzheimer’s diseases that affect the elderly. Aducanumab removes amyloid plaques, a protein deposit that is thought to play a role in attacking the condition on the brain.

    Questions about the efficacy of the drug have continued since it shook the US market and are highly controversial evidence that three FDA advisers resigned after June approval. European regulators have indicated that they do not recommend authorization.

    Critics warned that costly treatments could overwhelm the government’s health program, but sales were negligible, with Biogen and its partner Eisai Co. Disappointed investors in. Shares in June, when usage prospects still seemed bright, were close to $ 415. Since then, they have decreased by more than a third.

    Prescriptions for some patients are covered. Kaiser Permanente, a giant California-based health maintenance organization, said it would pay for the drug when its member doctors deem it medically necessary.

    Humana decisions for patients who meet the clinical trial criteria are not final, the spokesman said. Medicare-focused insurers continue to be concerned about drug data inconsistencies and said health program decisions will influence the final policy. Neither company states how many members received the drug.

    Other insurance companies are more restrictive. In a June news release of Biogen announcing the launch of the drug, Cigna Corp. executives said the company “ensures that patients who will most benefit from this new treatment have a clear path to access it. We are working on it. “

    Since then, Cigna has called the drug “unproven” and does not cover it according to its policy. In an email statement, the company quoted “new concerns about safety and effectiveness.”

    At First Choice Neurology, a large chain of clinics in southern Florida, about 80 patients are receiving Aduhelm, says clinic doctor Jeffrey Gellblum. He said some private insurance companies have approved claims for this drug without providing a name.

    Many patients who do not get the green light will get the drug for free from Biogen, at least temporarily, while the practice is appealing to the insurance company, he said, it will take months. You may. Gelblum said it was problematic for the drugs most likely to work early in the disease.

    “I don’t want to waste my time,” he said in an interview. “There is a two-year intervention period here. If the patient says,” This problem seems to be happening for one year, “you know that another year is the problem. “”

    Determining whether a patient is eligible for treatment can also be a barrier. One way to look for obvious amyloid plaques is with a PET scan of the brain. The procedure costs about $ 5,000 and is not paid by the insurance company.

    Some of Marwan Sabbagh’s patients at the Barrow Neurological Institute in Phoenix pay for the scans themselves. Another option is spinal puncture. Biogen may even cover the cost of analyzing a test. However, many are afraid of the procedure. The neurologist has offered to participate in clinical trials that are expensive to scan and treat.

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

    Major insurers that did not disclose their position at Aduhelm and did not answer Bloomberg’s questions include Anthem Inc., CVS Health Corp., and Centene Corp. UnitedHealthGroup Inc. Mentioned a comment in July. Evaluate the drug and wait for guidance from Medicare.

    Millions of patients will soon pay either way while the government health program is still deciding whether to cover aducanumab: Medicare premiums are about $ 11 per person per month in 2022. Rise and prepare for the potential cost of subsequent medications and similar treatments.

    Other insurers said they would cover aducanumab with plans to manage Medicaid, a state federal health program for low-income earners, as needed. Molina Healthcare Inc., which has 4.8 million members primarily in the Medicaid program, said Aduhelm will only be compensated if requested by the state.

    The drug is not included in the company’s products through the Affordable Care Act market, where individuals and families can purchase government-sponsored health insurance. Molina has not yet been requested to report, according to a spokeswoman.

    A spokesperson for a US agency said in an email that the state’s Medicaid program needs to cover the drug as Biogen participates in Medicaid’s drug rebate program.

    Most insurers who answered Bloomberg’s question said they would continue to evaluate new evidence and take into account Medicare’s decisions. As a condition of drug approval, Biogen must do another study to confirm the benefits of Aduhelm. In addition to the turmoil, Biogen said this month that the key figure behind Aduhelm, 64-year-old principal investigator Alfred Sandrock, will retire at the end of the year.

    Meanwhile, doctors and patients who want this drug are seeking it through clinical trials and Biogen’s access program. Jonathan Rhys, founder of the Columbus Memory Center in Georgia, said that two of his patients obtained the drug through a company program and he personally paid one-third of the cost. He said he was.

    Squirrel, who received money from Biogen to serve on an advisory board, says he is wary of starting patients with drugs that may have to be stopped if Medicare decides not to cover it. I did.

    “What I said to many patients is,’Look, I can get you drag“But I don’t know if it will be paid,” he said.

    Biogen CEO: “Major Bottlenecks” Still Limit Alzheimer’s Disease Drugs

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    Quote: The insurance company received Biogen’s $ 56,000 annual treatment for Alzheimer’s disease on November 22, 2021 from https: // Hesitate to pay (November 22, 2021) .html

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