The ACR Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care has been hard at work, advocating to payers on behalf of the ACR and its members. Following is an update on some of the work this group has been doing to help address concerns about reimbursement and administrative burden, while ensuring continued access to critical therapies for patients with rheumatic disease.
G2211 Outreach to Commercial Payers
UnitedHealthcare (UHC) began reimbursing the complex care add-on code G2211 on Jan. 1, 2024, for both commercial and Medicare Advantage plans. At the time, the ACR applauded the payer’s leadership among commercial plans for recognizing and investing in high-quality, patient-centered care. However, UHC later reversed its position and discontinued G2211 reimbursement for commercial plans on Sept. 1.
The ACR led a multispecialty sign-on letter to UHC urging the payer to reconsider; however, UHC remains committed to the decision, asserting that services associated with G2211 are already bundled into the payment for evaluation and management (E/M) services. UHC claims that, unlike the Centers for Medicare & Medicaid Services (CMS), it did not reduce reimbursement for E/M visits when G2211 was implemented.
ACR members should note that UHC commercial fee schedules are based off Medicare rates and could reflect this reduction in future contracting. The ISC continues to monitor this issue and advocate for appropriate recognition for the additional work involved with managing complex and chronic diseases.
The ISC also recently sent a letter to the other major commercial payers advocating for G2211 coverage. Currently, most commercial plans decline to reimburse the code, often citing a lack of guidance from the CMS.
Underwater Formulary Requirements for Biosimilars
The ISC continues to reach out to commercial health insurance payers whose formulary requirements would leave practices underwater when treating patients with certain biosimilar therapies, most often infliximab-axxq (Avsola) or infliximab-dyyb (Inflectra). Numerous payer formularies require patients to use specific biosimilars, despite reimbursement falling below acquisition cost for many independently owned rheumatology practices.
Although the ACR supports biosimilar use and is encouraged by their overall impact on reducing drug costs, requiring practices to infuse any drug at a loss undermines financial solvency, decreases patient access to treatment and is unacceptable.
The ISC has reached out to numerous health plans this year, encouraging them to either change their requirements or increase reimbursement for the underwater drugs. Most recently, the ISC sent a letter to Health Care Services Corporation (HCSC), which offers Blue Cross Blue Shield (BCBS) plans in Illinois, Montana, New Mexico, Oklahoma and Texas. The ISC urged HCSC to reconsider Jan. 1 formulary changes for infliximab products and ensure appropriate reimbursement rates.
Additionally, the Underwater Biosimilars Coalition, spearheaded by the ACR and the Coalition of State Rheumatology Organizations, continues its work to address these issues with agencies and Congress.
UHC Pharmacy Drug List Changes
The ISC has engaged in dialogue with UnitedHealthcare as the payer formalizes changes to its pharmacy drug list for 2025. One key coverage change to note is that UHC-preferred adalimumab products will include bio-originator adalimumab (Humira) in addition to biosimilars adalimumab-atto (Amgevita) and the unbranded version of adalimumab-adaz. In the IL-17 category, secukinumab (Cosentyx) will remain preferred; however, it will move from tier 3 to tier 2 and the current requirement to step through two other products will be eliminated.
Commercial plans routinely announce policy and formulary changes in October and November for the following year. The ISC is available to help members navigate these changes and advocate for your practice and patients. For more information about the issues above or to request ACR’s help on other specific payer issues affecting your practice, ACR/ARP members can reach out to [email protected].