The ISC has reached out to three payers—Aetna, Cigna and United Healthcare (UHC)—whose formularies all prefer Inflectra and/or Avsola over other infliximab biosimilars and with which rheumatology professionals have had the most concerns regarding reimbursement loss, Dr. Shepherd says. She summarizes these payer actions as a direct result of ACR advocacy:
- In response to concerns raised by the ACR, Aetna adjusted its fee schedule for commercial and Medicare Advantage plans in July 2023, increasing reimbursement for the underwater drugs.
- UHC is looking at a short-term solution to keep infusions in rheumatology practices instead of shifting patients to hospital outpatient settings. It is also exploring a longer-term solution that would help mitigate the impact of the instability in pricing for certain products.
- The ACR is in communication with Cigna to address biosimilar reimbursement for underwater drugs.
- The ACR is in the process of reaching out to the Centers for Medicare & Medicaid Services (CMS) to make it aware of reimbursement issues that might affect access to biosimilars to infliximab in the Medicare Advantage market.
In conversations with payers, the ACR is also communicating the cost reduction of branded drugs since the introduction of biosimilars. Specific to infliximab, the cost of the branded version Remicade has dipped 60% since biosimilars entered the market: at the end of 2016, the average sales price of Remicade was $828.72 compared to $326.37 at the end of 2023.
“Ultimately, we want payers to understand the ACR’s position that rheumatology practices should be appropriately reimbursed for using any version of the most cost-effective infusible biologic drug, whether it’s a biosimilar or not,” Dr. Shepherd adds.
Speak Up to Share Your Concerns with Biosimilars
Dr. Phillips and Dr. Shepherd encourage every ACR member to reach out with any issues regarding biosimilar drugs. They would especially appreciate any updates from ACR members with regard to Aetna reimbursement of biosimilars to infliximab in their practices.
Here are two ways rheumatology professionals can communicate biosimilar concerns to the ISC’s attention:
- Send an email to [email protected] with details about your concern.
- Submit insurance issues through a Health Insurance Complaint Form at https://rheumatology.org/insurance-advocacy.
Carina Stanton is a freelance science journalist based in Denver.
