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Study: Wide Inconsistencies in Medicaid, Commercial Coverage of Alzheimer’s Drug, Aduhelm

February 28, 2023

A comprehensive review study has found that Medicaid and commercial insurance coverage policies for Biogen Alzheimer’s disease drug, Aduhelm, showed large inconsistencies based on plan and geography.

A comprehensive review study has found that Medicaid and commercial insurance coverage policies for Biogen Alzheimer's disease drug, Aduhelm, showed large inconsistencies based on plan and geography. The paper, "Variation in Medicaid and Commercial Payer Coverage of Aducanumab for Alzheimer's Disease," was published today in Alzheimer's & Dementia: The Journal of the Alzheimer's Association.

"Medicare coverage of Aduhelm has received significant attention, and for good reason, ever since the FDA approved the drug in June 2021 and CMS restricted coverage 10 months later," said Pei-Jung Lin, PhD, Project Director of the Center for the Evaluation of Value and Risk in Health (CEVR) at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, and the study's lead author. "But there have been many unanswered questions about how Medicaid and commercial payers would approach Aduhelm coverage, which previously had been unexplored."

Researchers at CEVR reviewed the literature on U.S. health insurer coverage policies for Aduhelm and created a database of Aduhelm coverage policies issued by Medicaid fee-for-service programs in all 50 states, plus Washington D.C., and 35 of the largest U.S. commercial plans, covering approximately 84 percent of the commercially insured U.S. population. States are required to cover Aduhelm for qualified Medicaid beneficiaries, but upon analyzing the data, the researchers found that only 41 percent of Medicaid plans had made their coverage policies publicly available, and those plans featured substantial differences in eligibility requirements. And while 80 percent of commercial plans were found to have issued Aduhelm coverage policies, only five plans actually covered the drug for their policyholders.

"There were clear and striking differences between Medicaid and commercial payer coverage of Aduhelm," said James Chambers, PhD, Investigator at CEVR and the study's senior author. "There were also substantial discrepancies in coverage transparency among payers and in measuring sufficient treatment response."

The researchers also noted a number of cases in which coverage included step therapy protocols, in addition to a variety of access issues across states and jurisdictions.

"While our research provides excellent context on Aduhelm coverage, more data are needed to examine the health outcomes of the patients who did receive access to Aduhelm," said Dr. Lin. "We are keeping an eye on any revisions of Aduhelm coverage policies in response to future trial data and newly-developed Alzheimer's treatments, and how payers cover these new drugs as they are approved."

The study was funded by The Alzheimer's Association.

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