USA – UnitedHealthcare has announced it is limiting Aduhelm insurance coverage across all of its health plans, claiming that the drug “is unproven and not medically necessary for the treatment of Alzheimer’s disease due to insufficient evidence of efficacy,” according to the company’s new policies.
The coverage policy of the health insurance giant is consistent with Medicare’s recent coverage determination, with the insurer stating that it will cover the drug for people in clinical trials but will require prior authorization.
As Stat News notes, physicians who plan on giving Aduhelm to UnitedHealthcare patients will need to obtain prior approval from the insurance company, effective June 1. Patients also need to be in an approved clinical trial.
While pharmaceutical companies, patient advocates, and lawmakers were outraged by Medicare’s national coverage decision, health plans lauded it.
As the industry awaited final word from the Centers for Medicare & Medicaid Services, UnitedHealthcare was the first publicly traded insurer to issue a coverage determination for Aduhelm.
UnitedHealthcare cited multiple studies in its policy bulletin to support its decision, including an Institute for Clinical and Economic Review study that found no patient benefit from the drug when compared to existing supportive care strategies alone.
Last month, Medicare finalized a plan that would limit coverage for drugs that target amyloid beta plaques in people with Alzheimer’s disease or dementia to those who are enrolled in clinical trials.
It did, however, establish a new coverage pathway option that would expand coverage if a drug in this class received traditional FDA approval.
Aduhlem, developed by Biogen, is the only drug in its class to have received FDA approval, despite criticism from the healthcare industry and its own advisory committee.
Previously, Several Blues insurers decided not to include Aduhelm on formularies. Several health-care organizations, including the Cleveland Clinic, have stated that they will not prescribe the drug.
UnitedHealthcare, Kaia collabo on virtual therapy program
In other new developments, UnitedHealthcare and Kaia Health have collaborated on a new virtual physical therapy program.
According to the health insurance company, the program will provide 24/7, on-demand exercise feedback to eligible members with musculoskeletal conditions.
Members who are recovering from surgery or an injury will be asked to complete a current issues assessment and will be referred to the program based on the results of that assessment.
Eligible members can then download Kaia’s app to gain access to its physical therapy tools, which use artificial intelligence to guide patients through physical therapy exercises and track progress.
The app uses the camera on the mobile phone rather than a wearable device to track motion in real time and make suggestions.
When combined with user-reported data, the app can determine when a member may require additional coaching or intervention to ensure they are meeting their physical therapy goals.
Participants in the program can also get one-on-one health coaching by phone or through the app’s chat feature.
These health coaches provide encouragement and guidance, as well as a link to the patient’s care team if potential problems are identified.
The new virtual physical therapy option is part of UnitedHealthcare’s larger push for more virtual plan solutions, and it is available to self-funded employer clients nationwide.