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Aetna Classifies Aduhelm As A Medically Necessary Drug

Aetna Inc a health care company that sells traditional and consumer-directed healthcare insurance and related services, such as medical, pharmaceutical, dental, and behavioral health says it considers Aduhelm to be medically necessary.

According to the healthcare company, it will cover the controversial Alzheimer’s drug if certain criteria are met. The payer will require pre-authorization for all providers and members covered under plans where the new policy applies.

Under the new policy, the drug must also be prescribed by or in consultation with a gerontologist, neurologist, psychiatrist, or neuropsychiatrist.

“Aetna Clinical Policy Bulletin (CPB) for coverage of Aduhelm was adapted from, and is aligned with, the Centers of Medicare & Medicaid Services (CMS) National Coverage Determination (NCD),” an Aetna spokesperson told Becker’s. “Precertification is required and includes the requirement for enrollment in a randomized controlled trial conducted under an investigational new drug (IND) application or National Institutes of Health (NIH)-supported the trial.”

The move follows CMS’ decision in April to only cover Aduhelm for Medicare members participating in clinical trials. In May, UnitedHealthcare deemed it “unproven and not medically necessary” and said it would only cover the drug for members in clinical trials who have received prior authorization.

The drug manufactured by Biogen faced a slow rollout amid criticism of its high cost, potentially severe side effects, and conflicting trial results over its effectiveness.

The intense debate over whether it worked and the FDA process to approve it led to large payers refusing to cover the drug last fall until more evidence was available.

To encourage coverage from commercial and public plans, Biogen cut the drug’s annual price tag from $56,000 to $28,000 in January. Commercial payers were largely waiting on an early coverage decision from CMS before making their own decisions, despite physicians calling for coverage only during clinical trials.

In August, Biogen initiated layoffs and began cutting office space to save on costs after the drug proved to be largely unpopular with payers and providers. 

The new Aetna policy can be viewed in full here.

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