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Anthem to Cover Exact Sciences' Cologuard under Certain Circumstances

NEW YORK (GenomeWeb) – Anthem will cover Exact Sciences' colorectal screening test as a medically necessary procedure under certain conditions, the insurer said in a policy statement on Thursday. 

In its updated policy Anthem said that it will cover the Cologuard test as a medically necessary test once every three years "as a screening technique for individuals in whom colon cancer preventive screening is indicated." For other circumstances, the test is considered investigational and not medically necessary and will not be covered by Anthem.

The insurer has more than 68 million people covered by its affiliated companies, including more than 37 million lives in its health plans. 

Anthem becomes the second national payor to provide coverage for Cologuard this week, following Aetna, which is covering Exact Sciences' non-invasive test under its Medicare Advantage plan, which serves 967,000 members nationwide.

According to Jefferies analyst Brandon Couillard, Anthem will cover the test as an out-of-network benefit and will reimburse for the test at out-of-network pricing levels. He added that the updated policy will allow Exact Sciences to begin formal contract talks with Anthem to get in-network status and to be paid accordingly. 

William Blair's Brian Weinstein called Anthem's coverage decision "a significant positive" for Exact Sciences "as it shows that a major payer has come to the realization that the clinical benefits of this test are meaningful and that their members should have access to this product on a three-year interval." 

Cologuard simultaneously received approval by the US Food and Drug Administration and a national coverage determination by the Centers for Medicare and Medicaid Services last summer.

In afternoon trading on the Nasdaq, Exact Sciences' shares rose 9 percent to $24.51.