In a reversal, state’s largest private insurer will cover new Alzheimer’s drug from Biogen
Blue Cross Blue Shield of Massachusetts initially balked at covering the treatment — which costs $26,500 per year per patient — because it considered Leqembi “investigational,” or experimental. The Massachusetts state's largest private insurer, Blue Cross Blue Shield, has reversed its decision to not cover the new Alzheimer's drug, Leqembi, which was fully approved by the Food and Drug Administration nearly nine months ago and is currently being adapted to Medicare coverage criteria for commercial patients. The drug, which costs $26,500 per year per patient, was initially considered "investigational" or experimental by the insurer as it considered it to be a drug that could slow cognitive decline in early Alzheimer's patients. However, following an inquiry by The Boston Globe, BlueCross Blue Shield announced it would extend coverage to its commercial customers. The company, which administers Medicare Advantage plans on behalf of the federal government, was covering the drug for those beneficiaries and was covering those beneficiaries for those of those who are not eligible for Medicare. Despite raising the risk of brain swelling and bleeding in some patients in clinical trials, the drug was approved without raising a "black box" warning.
Veröffentlicht : Vor 2 Monaten durch Jonathan Saltzman in Business Health
However, in response to an inquiry by The Boston Globe, the insurer said on Friday that it would extend coverage of Leqembi to its commercial customers. Like other private insurers, Blue Cross Blue Shield administers Medicare Advantage plans on behalf of the federal government and was covering the drug for those beneficiaries.
The drug, called Leqembi, was fully approved by the Food and Drug Administration nearly nine months ago and covered by Medicare, the government health insurance program for the elderly. But Blue Cross Blue Shield of Massachusetts balked at covering the treatment — which costs $26,500 per year per patient — because it considered Leqembi “investigational,” or experimental.
The state’s largest private health insurer said it will cover the first drug to slow cognitive decline in early Alzheimer’s patients, reversing an earlier decision not to pay for the treatment.
“Our internal team is currently working with local specialists who offer this treatment to adapt Medicare coverage criteria for commercial patients,” Amy McHugh, a spokesperson for Blue Cross Blue Shield, said in an email.
She added that only two commercial customers of Blue Cross Blue Shield had been denied coverage.
Doctors were both angered and puzzled by Blue Cross Blue Shield’s initial decision to not cover the Alzheimer’s drug. Since the vast majority of Alzheimer’s patients are 65 or older and most of them are on Medicare, the number of commercial insurance customers seeking the treatment is relatively small, doctors said.
Nonetheless, patients younger than 65 — on rare occasions as young as their 30s — are sometimes diagnosed with Alzheimer’s and aren’t eligible for Medicare. The disease is called “early-onset Alzheimer’s” in those patients.
McHugh said FDA approval was only one of five criteria that the insurer had to consider when deciding whether to pay for Leqembi. Among the other factors was whether the benefits of the drug outweighed its risks.
Jointly developed by Cambridge-based Biogen and its Japanese business partner Eisai, Leqembi did raise the risk of brain swelling and bleeding in some patients in clinical trials. That prompted the FDA to issue a “black box” warning when it approved the drug on July 6 last year.
But Dr. Andrew M. Stern, a neurologist at Brigham and Women’s Hospital who has prescribed Leqembi to patients with early Alzheimer’s symptoms, noted in a series of emails to Blue Cross Blue Shield that the drug had undergone extensive testing in a large late-stage clinical trial and won full approval from regulators. Blue Cross Blue Shield, he said, was the only private insurer he had encountered that had refused to cover it.
“Leqembi is no more investigational than any other newly FDA approved drug,” Stern told the Globe.
Stern said he was aware of one patient at Brigham who was prescribed Leqembi and denied coverage by Blue Cross Blue Shield. He said he was relieved that the insurer had reversed itself.
“I’m still not pleased with their overall handling of the drug, but they’ve done what’s right,” he said.
About 100 patients at Mass General Brigham, parent company of Brigham and Massachusetts General Hospital, have started to receive intravenous infusions of Leqembi every two weeks or are scheduled to receive them, according to a Mass General Brigham spokesperson.
Leqembi is the first medicine to convincingly show it can slow the cognitive decline caused by early-stage Alzheimer’s, though only modestly. In clinical trials, it removed clumps of a sticky protein called beta-amyloid from the brain, a hallmark of the disease.
Blue Cross Blue Shield has about 3 million members in Massachusetts.
Jonathan Saltzman can be reached at [email protected].