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Humana To Begin Covering Exact Science's Cologuard In 2017

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Humana To Begin Covering Exact Science's Cologuard In 2017
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Humana Inc (NYSE: HUM) has finally come around after showing intransigence in including EXACT Sciences Corporation (NASDAQ: EXAS)'s Cologuard test in its coverage policy.

Humana's Commentary

A Humana spokesperson told Benzinga exclusively that starting January 1, 2017, "Humana's Commercial members may be eligible under their plan for the Cologuard test once every three years. Members may be eligible if they are age 50 years and older and are considered an average risk individual, which is someone without a personal history of colon polyps, colorectal cancer (personal or family history), high-risk genetic syndromes, or inflammatory bowel disease."

"The Centers for Medicare & Medicaid Services (CMS) has determined that the Cologuard test is covered once every three years for Medicare beneficiaries that meet specific criteria. In accordance with CMS guidance, Humana will allow for this service for our Medicare Advantage members when the specified criteria are met," he added.

Cologuard is a non-invasive, stool DNA colorectal cancer screening test developed by Exact Sciences. This test was approved by the FDA in August 2014.

Lawsuit

In February this year, Exact Sciences said it would sue Human for refusing to pay for 4664 screenings of Humana enrollees, with outstanding claims worth over $800,000. The case was filed in Kentucky, one of the 30 states that have mandated coverage of colorectal cancer screening tests.

The lawsuit also claimed that fliers circulated to Kentucky physicians questioned the effectiveness of Cologuard. Exact Sciences had expressed its misgivings that the fliers might have been circulated nationwide.

Humana, meanwhile, agreed to process claims for reimbursement denied beginning in January 2016. However, Exact Sciences is seeking coverage of all outstanding claims in all states.

Uncertainties Remain

Now with Humana budging, it still remains unclear if the coverage is just for new claims, starting in 2017, or it would process even the previous outstanding claims. If Humana is forced to backdate its coverage, then it might have shell out a considerable sum toward it.

Exact Sciences' webpage on Cologuard lists Aetna Inc (NYSE: AET) Medicare Advantage and Anthem Inc (NYSE: ANTM) Blue Cross & Blue Shield as insurers covering the test nationally. The page also lists region-wide insurance providers who cover the test.

Exact Sciences has yet to respond to Benzinga's call on the development.

In pre-market trading, Humana shares were seen up 0.97 percent at $208.70.

Posted-In: Cologuard colorectal cancerBiotech News Health Care Movers Trading Ideas General Best of Benzinga

 

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