UnitedHealthcare has revised its community and commercial plans’ coverage of erythropoiesis-stimulating agents. Effective January 1, 2020, patients who are receiving the reference epoetin alfa, Epogen or Procrit, will be required to switch to Pfizer’s biosimilar, Retacrit.
UnitedHealthcare has revised its community and commercial plans’ coverage of erythropoiesis-stimulating agents. Effective January 1, 2020, patients who are receiving the reference epoetin alfa, Epogen or Procrit, will be required to switch to Pfizer’s biosimilar, Retacrit.
Patients who wish to remain on the reference epoetin alfa will need to meet medical necessity criteria; Epogen or Procrit are considered medically necessary if a patient had minimal clinical response to Retacrit and a physician attests that a superior response would be expected from Epogen or Procrit, or if the patient has a history of intolerance to, contraindication to, or failure of Retacrit that a physician attests would not be expected with Epogen or Procrit.
Additionally, coverage for Retacrit will not require prior authorization for patients who meet diagnosis-specific criteria for indications including anemia due to chronic kidney disease, anemia due to chemotherapy, and anemia associated with myelodysplastic disease, among others.
The new policy does not apply to community plans in Kansas or Louisiana.
This revision to UnitedHealthcare’s coverage comes after the payer made a prior notable move to prefer biosimilars of anticancer drugs. In August of this year, UnitedHealthcare indicated that, starting in October, it would prefer biosimilar bevacizumab (Mvasi) and biosimilar trastuzumab (Kanjinti), both made by Amgen, to the reference drugs, Avastin and Herceptin, respectively.
It also has made biosimilar filgrastim (Zarxio) a preferred product over follow-on filgrastim (Granix, or tbo-filgrastim), the reference filgrastim (Neupogen), and a competing biosimilar filgrastim (Nivestym).
Finally, a representative from UnitedHealthcare previously told The Center for Biosimilars® in an email that it planned to add biosimilar infliximab (Inflectra) to a preferred position along with the brand-name infliximab (Remicade).
Biosimilar Market Development Requires Strategic Flexibility and Global Partnerships
April 29th 2025Thriving in the evolving biosimilar market demands bold collaboration, early global partnerships, and a fresh approach to development strategies to overcome uncertainty and drive future success.
How AI Can Help Address Cost-Related Nonadherence to Biologic, Biosimilar Treatment
March 9th 2025Despite saving billions, biosimilars still account for only a small share of the biologics market—what's standing in the way of broader adoption and how can artificial intelligence (AI) help change that?
President Trump Signs Executive Order to Bring Down Drug Prices
April 16th 2025To help bring down sky-high drug prices, President Donald Trump signed an executive order pushing for faster biosimilar development, more transparency, and tougher rules on pharmacy benefit managers—aiming to save billions and make meds more affordable for everyone.
Will the FTC Be More PBM-Friendly Under a Second Trump Administration?
February 23rd 2025On this episode of Not So Different, we explore the Federal Trade Commission’s (FTC) second interim report on pharmacy benefit managers (PBMs) with Joe Wisniewski from Turquoise Health, discussing key issues like preferential reimbursement, drug pricing transparency, biosimilars, shifting regulations, and how a second Trump administration could reshape PBM practices.