This week, the insurer rolled out some of the changes it will be implementing in its Medicare Advantage (MA) plans as of January 1, 2019.
When CMS announced in August 2018 its policy change to allow Medicare Advantage (MA) plans to utilize step therapy as a way to negotiate drug prices, UnitedHealthcare, the nation’s largest MA carrier, publicly celebrated the decision. This week, the insurer rolled out some of the changes it will be implementing in its MA plans as of January 1, 2019.
In a bulletin released this month, UnitedHealthcare stated that it will employ step therapy to control costs of biologics, such as reference infliximab, sold as Remicade. Now listed as preferred drugs on its MA plan, which requires the product to be used first before a patient moves to another therapy, are infliximab biosimilars, Inflectra and Renflexis.
In addition, UnitedHealthcare has also listed biosimilar epoetin alfa, sold as Retacrit, as a preferred drug; however, it noted that step therapy will not apply to this product, or to patients already taking epoetin.
UnitedHealthcare also wrote that biosimilar pegfilgrastim, sold as Fulphila, and biosimilar filgrastim, sold as Nivestym, will require prior authorization when administered to patients with cancer in an outpatient setting.
When CMS Administrator Seema Verma announced the change in policy for MA plans, she indicated that it was her hope for MA plans to begin treatment with a cost-effective biosimilar before progressing to a more expensive therapy if the treatment was ineffective. Notably, however, she did not specify whether patients would be switched to a biosimilars reference product, or whether patients would be required to begin treatment with a biosimilar of one therapy before being permitted to cycle to a different biologic treatment altogether.
Contrary to UnitedHealthcare welcoming this policy change, rheumatology and oncology providers have expressed concern over the move, as step therapy, often referred to by critics as “fail-first,” can be harmful to patients with chronic conditions.
When speaking about step therapy proposals as a whole, the American College of Rheumatology (ACR) president, David Daikh, MD, PhD, said “While we support the goal of decreasing the cost of medications, the ACR has long opposed step therapy and other utilization management techniques that undermine the clinical judgement of providers, delay access to needed treatments, and put our patients’ health at unnecessary risk.”
Echoing this concern, The Community Oncology Alliance president called the change the “antithesis of where personalized cancer treatment is going,” and spoke out against the “one-size-fits-all” approach of treatment.
As of now, UnitedHealthcare is the only major insurer to publicly announce employing step therapy in its MA plans for 2019. In an email to The American Journal of Managed Care®, a sister site of The Center for Biosimilars®, a representative from Aetna explained that it is still evaluating whether or not to employ step therapy, and a representative from Kaiser Permanente confirmed that it will not be utilizing step therapy in 2019, but is evaluating making the change in 2020.