Changes to Medicare Advantage Plans May Boost Biosimilar Use

October 19, 2018

Biosimilars Team

Some recent developments involving Medicare Advantage plans may help to encourage uptake of biosimilars in the United States.

In August, the Centers for Medicare & Medicaid Services (CMS) announced that beginning January 1, 2019, Medicare Advantage plans would be permitted to implement step therapy to manage physician-administered and other Part B drugs as part of broader care coordination activities that include patient rewards and incentives. As explained by CMS, step therapy is a type of prior authorization that requires drug therapy for a medical condition to be initiated with the most preferred medication and progress to other therapies only if necessary, promoting better clinical decisions. CMS provided the specific example of using step therapy to ensure that a senior who is newly diagnosed with a condition begin treatment with a cost-effective biosimilar before progressing to a more costly drug therapy.

In its October 2018 Network Bulletin, UnitedHealthcare announced that it will require step therapy authorization for certain biologics in Medicare Advantage Plans. The infliximab biosimilars Inflectra (infliximab-dyyb) and Renflexis (infliximab-abda)—both listed as preferred drugs—must be used first before coverage for non-preferred reference infliximab (Remicade) will be considered. The epoetin alfa biosimilar Retacrit (epoetin alfa-epbx) is listed as preferred and must be used before the non-preferred drugs Procrit (epoetin alfa) and Aranesp (darbepoetin alfa). When members receive a lower cost preferred drug, the savings to the plan will be shared with the member as part of participation in the care coordination program.

UnitedHealthcare states that step therapy prior authorization requirements will not apply for members who are currently and actively receiving medications/medical devices (members with a paid claim within the past 120 days) on the list. In addition, Epogen (epoetin alfa) and Mircera (methoxy PEG-epoetin beta) are not subject to the step therapy requirement.

According to CMS, there currently are more than 20 million beneficiaries enrolled in Medicare Advantage plans.