Earlier this month, Rep. Bob Onder, MD (R-MO) led a letter signed by members of the GOP Doctors Caucus encouraging the Centers for Medicare and Medicaid Services (CMS) to “protect Medicare Advantage beneficiaries who are being blocked from lifesaving physician-administered treatments.”
The problem is reimbursement rates for biologics are lower than acquisition costs for physician practices. Reimbursement is based on average sales price (ASP), which is calculated by quarterly sales prices reported by drug manufacturers to CMS. These sales prices take into account rebates between health plans and pharmacy benefit managers (PMBs). Consequently, the rebated sales prices submitted to CMS are artificially lowering the ASP.
If a physician cannot afford to administer a biologic or biosimilar that is preferred, patients are often blocked from bypassing the preferred biologic because of step therapy, or ‘fail first,” requirements.
The letter asks CMS to pursue rulemaking to establish minimum national formulary adequacy standards for drug coverage in Medicare Advantage (MA). A formulary adequacy standard could be structured such that any biosimilar placed in a fail-first position by MA plans be reasonably available to network providers and, if not, that plans permit timely access to an alternative biosimilar or the reference biologic without additional utilization management.
ASGE worked alongside the rheumatology community to generate the letter to CMS and is grateful to Rep. Onder for his leadership on this important issue.