UnitedHealthcare limits Aduhelm for all health plans: 'unproven and not medically necessary' 

UnitedHealthcare plans will only pay for the controversial Alzheimer's drug Aduhelm for patients in clinical trials who have received prior authorization, according to a medical policy update filed May 1.

The payer said the change in coverage is because the drug is "unproven and not medically necessary for the treatment of Alzheimer's disease due to insufficient evidence of efficacy."

The new policy applies to commercial, individual and Medicare members. It goes into effect June 1.

The move follows CMS' decision in April to only cover Aduhelm for Medicare members participating in clinical trials.

"Consistent with the National Coverage Determination recently finalized by CMS, we will only offer coverage of Aduhelm for Medicare members who are enrolled in approved clinical trials of the drug and for Medicaid members when directed by a state," a United spokesperson told Becker's in a statement. "We will continue to monitor ongoing clinical studies, as well as guidance from CMS and other agencies, and will update our clinical and coverage policies as necessary."

The drug manufactured by Biogen faced a slow rollout amid criticism of its high cost, severe potential 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 price tag from $56,000 to $28,000 in January. Commercial payers were largely waiting on an early coverage decision from CMS before following suit, despite physicians calling for coverage only during clinical trials.



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