Aetna Revises Reimbursement Policy For Anemia Medications After CMS Decision

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Blood / Hematology;  Health Insurance / Medical Insurance;  Regulatory Affairs / Drug Approvals
Article Date: 22 Oct 2007 - 3:00 PDT

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Aetna this month revised the reimbursement policy for several anemia medications -- Aranesp and Epogen, marketed by Amgen, and Procrit, marketed by Johnson & Johnson -- after CMS recently announced a decision that will limit Medicare coverage for the medications, the Los Angeles Times reports (Costello, Los Angeles Times, 10/19).

According to a 61-page "national coverage determination" announced in July, Medicare will cover the medications, synthetic forms of the protein erythropoietin, to treat anemia caused by chemotherapy but not anemia caused by cancer. Under the decision, Medicare will cover the medications to treat anemia in cancer patients whose hemoglobin levels decrease to less than 10 grams per deciliter of blood. The decision will allow local Medicare contractors to determine whether to cover the medications to treat patients with myelodysplastic syndrome, a condition that can lead to leukemia (Kaiser Daily Health Policy Report, 10/17).

According to the Times, the Aetna policy, which is "slightly less restrictive than Medicare's but severe nonetheless," requires patients to have lower hemoglobin levels before they receive the medications but includes an exception for patients with higher hemoglobin levels who have anemia symptoms. Rachelle Cunningham, an Aetna spokesperson, said, "Our criteria are consistent with those of medical societies with regard to the treatment of anemia in patients on chemotherapy or who have chronic renal disease."

Aetna likely will face criticism about the policy from members and some physicians. Amgen spokesperson David Polk said, "The Aetna policy is much better aligned" with FDA recommendations and "guidelines from the leading oncology medical societies than Medicare's policy."

Analysts said that other health insurers likely will implement policies similar to the Aetna policy. Bear Stearns biotechnology industry analyst Mark Schoenebaum said, "Aetna is likely to be the first of many insurers to change their guidelines" (Los Angeles Times, 10/19).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

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