The ACR-led Underwater Biosimilars Coalition will meet with the Medicare Payment Advisory Commission (MedPAC) to discuss concerns about inadequate reimbursement for certain biosimilars, which has limited beneficiary access to these lower-cost alternative therapies. The ACR established the coalition earlier this summer after hearing from rheumatology practices and patient advocacy organizations about this challenge, and it has grown to include more than 40 stakeholder groups.
By statute, Medicare reimburses provider-administered drugs, including biosimilars, based on their Average Sales Price (ASP) plus 6%, with certain biosimilars paid at ASP+8%. A variety of issues have led to low ASPs for these drugs, making them difficult—if not impossible—for rheumatologists to acquire and prescribe to their patients. Further complicating the issue are utilization management requirements by private payers, including Medicare Advantage plans, that put “underwater” biosimilars as a first-line therapy, despite the low reimbursement.
As a legislative branch agency, MedPAC advises the Congress on issues affecting the Medicare program and provides information on access to care, quality of care and other issues affecting Medicare. The Commission has made several recommendations to Congress on Part B drug payment and policy, most recently as part of its June 2023 Report to the Congress. The Coalition will urge MedPAC to consider its concerns as the Commission continues to analyze and study drug payment and policy issues in the Medicare program.
ACR/ARP members should email the ACR’s advocacy team at [email protected] with any questions and comments they may have on the Coalition’s progress. We will continue to update membership on underwater biosimilars and can serve as an educational resource for members on any regulatory or legislative endeavor that impacts their acquisition and infusion.
