Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2023 Title: FEHB Policy for Aduhelm
Revision Date: Document: BI708:00
CPT Code(s): J0172
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    This policy applies only to the Federal Employee Health Benefits (FEHB) plan.

2)    Aduhelm (aducanumab-avwa) requires prior authorization.

3)    Aduhelm is used in the treatment of mild Alzheimer’s disease.

4)    Aduhelm is specialty drug covered under the medical benefit.


Medical Statement

Initial Approval Criteria

Aduhelm (aducanumab-avwa) is considered medically necessary when the member meets all of the following criteria:

 

1)    Diagnosis of mild cognitive Alzheimer’s disease or mild Alzheimer’s disease dementia;

2)    Presence of beta-amyloid plaques verifiedby one of the following (a or b):

a.    Positron emission tomography scan;

b.    Cerebrospinal fluid testing

3)    Member meets one of the following (a or b):

a.    Member is enrolled in a randomized, controlled trial conducted under an investigational new drug application;

b.    Member is enrolled in a National Institute of Health-supported trial.

 

Continuation of Therapy Criteria (must meet all)

1)    Member meets one of the following (a or b):

a.    Member is enrolled ina randomized, controlled trial conducted under an investigational new drug application;

b.    Member is enrolled in a National Institute of Health-supported trial.

 

Codes Used In This BI:

 

J0172 Injection, aducanumab-avwa, 2mg


Reference

1. Aduhelm Prescribing Information. Cambridge, MA: Biogen, Inc.; July 2021. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/761178s000lbl.pdf. Accessed February 16, 2022.

2. Centers for Medicare & Medicaid Services. Monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease. Medicare Coverage Database. CAG099469N; 2022. Available at: https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=305. Accessed April 19, 2022.

3. ClinicalTrials.gov. 221AD301 Phase 3 Study of Aducanumab (BIIB037) in Early Alzheimer`s Disease (ENGAGE). Available at: https://clinicaltrials.gov/ct2/show/NCT02477800. Accessed February 16, 2022.

4. ClinicalTrials.gov. 221AD302 Phase 3 Study of Aducanumab (BIIB037) in Early Alzheimer`s Disease (EMERGE). Last updated May 6, 2021. Available at: https://clinicaltrials.gov/ct2/show/NCT02484547. Accessed February 16, 2022.

5. Peripheral and Central Nervous System (PCNS) Drugs Advisory Committee Meeting. Combined FDA and Applicant PCNS Drugs Advisory Committee Briefing Document. November 6, 2020. Available at: https://www.fda.gov/advisory-committees/advisory-committee-calendar/november-6-2020-meeting-peripheral-and-central-nervous-system-drugs-advisory-committee-meeting#event-materials. Accessed February 16, 2022

6. Institute for Clinical and Economic Review: Final Evidence Report and Meeting Summary - Aducanumab for Alzheimer’s disease: Effectiveness and Value. August 5, 2021. Available at: https://icer.org/wp-content/uploads/2020/10/ICER_ALZ_Final_Report_080521.pdf. Accessed February 16, 2022.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.