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VIDEOAetna Confirms It Will Cover Provenge
On June 15, six weeks after Provenge was approved, Aetna issued its opinion that Dendreon's drug was medically necessary and would be covered.
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The National Comprehensive Cancer Network (NCCN) Compendium listed Provenge as part of standard therapeutic practice for metastatic, hormone-refractory prostate cancer within two weeks of approval. This was a strong signal to doubters that insurance reimbursement wasn't going to be a tortured process since most insurers take their cue from compendia like NCCN. The very short time between drug approval and the NCCN compendia listing is remarkable and unusual. It's an indication of how active Dendreon has been over the past several months working the issue of reimbursement.
On June 15, six weeks after Provenge was approved, Aetna (AET) issued its opinion that Provenge was medically necessary and would be covered.
Dendreon bears have maintained that Dendreon would find it difficult to secure insurance reimbursement. Further, the ursine argument goes, if reimbursement was allowed, it would be so wrapped up in red tape as to dramatically reduce the total covered population. The announcement by Aetna, who has over 36 million lives covered, pokes very big holes in both arguments.
First, Aetna's coverage decision is relatively rapid. At just six weeks after approval, this means Aetna personnel were working on this issue before Provenge was even approved. Score another one for Dendreon's coverage-outreach team.
Second, Aetna's coverage rules don't differ meaningfully from Provenge's approved label. The only departure I can see in the rules is a requirement that the patient be on hormone therapy for at least three months. Since the most common hormone therapy uses either a one-, three-, or six-month depot system, this is no kind of barrier at all. So there's no indication Aetna is trying to ration access to the drug. For this major insurer at least, the bears strike out again.
Bottom line is, I continue to expect little pushback from insurers despite the apparent high price tag for the drug. I say "apparent" because the lifetime cost to receive Provenge is cheaper than some other biologics, and the cost per month of added survival is often cheaper than the chemotherapy drug also approved for late-stage prostate cancer once treatment for typical chemotherapy side effects and long duration of treatment are factored in.
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