Major insurers won't pay for Biogen's Alzheimer’s drug until they get more proof that it works: Bloomberg survey

Biogen
Insurers are asking for more proof that a controversial Alzheimer's disease drug made by Biogen is medically necessary, a new survey from Bloomberg found. (Biogen)

More than two dozen major health insurers don’t believe that a controversial Alzheimer’s drug manufactured by Biogen and costing $56,000 a year is medically necessary, according to a survey conducted by Bloomberg News.

The survey of the 25 major insurers showed most payers believe the drug, Aduhelm, is too experimental. The results come as Medicare is bracing for coverage of the drug, which could be a major hit to the program’s budget.

Bloomberg reported that insurers in the survey were unsure about the benefits and side effects of the drug, which was approved by the Food and Drug Administration in June after objections from its own advisers.

Some major insurers such as Anthem and CVS-Aetna did not respond to Bloomberg’s survey, and UnitedHealth Group previously said it is awaiting Medicare’s decision, according to Bloomberg.

But some large providers and other payers have already announced their decision to not cover the drug, which was approved in June to treat Alzheimer’s but with remaining questions on its effectiveness.

RELATED: Part B premiums set to rise in 2022 as Medicare braces for potential high-cost therapies like Aduhelm

New York-based Excellus BlueCross Blue Shield said back in August it won’t cover Aduhelm, and insurer Highmark will only cover it with prior authorization.

Larger providers such as Cleveland Clinic and Mount Sinai also said they will decline to cover the drug.

The Department of Veterans Affairs has decided not to include Biogen’s drug aducanumab on its national formulary over “the risk of significant adverse drug events” plus a “lack of evidence of a positive impact on cognition,” Fierce Pharma reported.

The Centers for Medicare & Medicaid Services announced that it is advising state Medicaid programs to cover the drug since Biogen participates in Medicaid’s rebate program.

Medicare itself hasn't made a decision yet on whether to cover the drug, but regulators are already bracing for its impact. The agency said Medicare Part B premiums are set to rise by 15% to brace for increases on prescription drug prices. 

Steeped in controversy since its June approval and saddled with a much-criticized price of $56,000 per year, the fate of Aduhelm appears dependent on whether Medicare will provide coverage for the drug and for others in its class of monoclonal antibodies that target amyloid plaque buildup. That process is due to complete in April 2022.

In October, Biogen revealed shockingly low sales of the newly launched Alzheimer's treatment. Third-quarter sales of the drug—once hailed as a first-of-its-kind breakthrough—only came to $300,000. The paltry figure didn’t approach the analyst consensus of $14 million, Fierce Pharma reported.