American Society of Hematology (04/09/2015)

The Centers for Medicare & Medicaid Services (CMS) in March issued two documents on Medicare Part B and Part D payment for biosimilars. The document related to Medicare Part B removes a provision that would lead to lower reimbursement rates for physicians who prescribe less expensive biosimilars instead of reference biologics. Medicare will pay the average sale price (ASP) of the biosimilar drug plus an amount equivalent to 6 percent of the higher-cost reference biologic. Until biosimilars have an established ASP, Medicare will pay 106 percent of the manufacturer's wholesale acquisition cost. The document related to Medicare Part D addresses the current formulary requirement that insurance plans offer two distinct drugs in each class. CMS will address formulary changes involving biosimilars on a case-by-case basis, but reference biologics and biosimilars "will not be considered as different drugs for the purpose of satisfying the two distinct drugs requirement." CMS does not believe that biosimilars are different enough to be considered a separate drug within a drug class, so biosimilars could potentially take the place of a reference biologic on a plan formulary.

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