American Academy of Ophthalmology accused major health insurance companies of using a shortage of biologics as a means to nudge patients to use biosimilar drugs to treat common retinal disease, even though the drugs have not been tested for such use.
A San Francisco lobby group has called on seven health insurers to stop recommending the use of two biosimilars for Avastin from Genentech USA, a biological drug used to treat eye conditions such as age-related macular degeneration and certain cancers. The industry group asked CMS to stop insurance companies from pressuring patients to take biosimilars from Pfizer’s Zirabev and Amgen’s Mvasi for age-related macular degeneration, which is the leading cause of blindness in people over 60 and affects approximately 15 million people in the U.S.
“Insurance companies are pushing ophthalmologists to use new biosimilar drugs as alternatives that have never been tested in the eye, essentially making patients who depend on this widely used drug unwitting participants in a clinical experiment,” the AAO said in a statement.
Unlike chemically derived generics, biosimilars cannot promise to be exact replicas of the parent biologics. Biologics are grown from living organisms such as cell tissue, bacteria or proteins, which means they can mimic the original drugs, but not exactly duplicate them.
Biosimilars are seen as a promising way to reduce drug costs – Pacific Research Institute Study 2019 It is estimated that biosimilars save commercial insurers $ 136.8 million a year, and if their coverage is expanded to 75% of biological prescriptions, the US healthcare system will save nearly $ 7 billion every year.
So far, the Food and Drug Administration (FDA) has approved about 30 biosimilar drugs, including Zirabev and Mwasi, which the FDA has approved as chemotherapy treatments for five types of cancer. But the federal agency did not approve them specifically for macular degeneration.
Neither Pfizer nor Amgen list biosimilars as eye treatment options on their websites.
“Even drug makers do not recommend injecting alternative medications into the eyes because there is no scientific evidence to support this,” the AAO said in a statement claiming that Zirabev could even accelerate exacerbation of eye disease in patients.
Insurance companies are apparently cashing in on the Avastin shortage caused by Optum UnitedHealth Group, one of the world’s largest biologics suppliers. Optum is currently updating its security-related distribution process, which prevents it from shipping the drug, according to the AAO. This has led some ophthalmologists to struggle to find a creator.
Optum declined to comment on the matter.
AAO claims that UnitedHealthcare, Aetna, Humana, Carefirst Blue Cross and Blue Shield, Horizon BCBS from New Jersey, AmeriHealth and HealthAssurance Pennsylvania have begun recommending Zirabev and Mwasi biosimilars to patients due to a shortage of Avastin.
Since July 1, UnitedHealthcare of Minnetonka, Minnesota, has limited the use of Avastin and biosimilars by commercial participants to once a month in each eye for the first year and “fewer injections required in subsequent years.” IN updated policy document lists biosimilars as treatment options for age-related macular degeneration in commercial and Medicare Advantage members. UnitedHealthcare did not respond in due time to the interview request.
Aetna spokesperson pointed to June policy document by the Woonsocket insurance company, which lists biosimilars as an approved therapy for the treatment of eye diseases for its commercial and Medicare members.
CareFirst contested the AAO’s claims, stating that the Baltimore-based insurance company does not support the use of both biosimilars for retinal disorders and cites Avastin as the preferred treatment. Horizon BCBS, based in Newark, NJ, also said its AAO policy profile was incorrect.
“Horizon’s policy regarding the use of an approved biosimilar for Avastin applies only to its use by patients with certain cancers and newcomers to treatment,” a Horizon spokesperson said in a statement. “When it comes to ophthalmic use for treating eye diseases, the academy was wrong – there is no policy requiring the use of the Avastin biosimilar for any Horizon member.”
Louisville, Kentucky, Humana, Cranbury, NJ, AmeriHealth and North Bethesda, Maryland, HealthAssurance Pennsylvania did not respond to interview requests.
The AAO report comes as health insurers increasingly oppose members’ use of high-value biologics, and this year UnitedHealthcare, Aetna and Cigna unveiled rules forcing patients to biosimilar or limit the dosage of drugs a person can receive. Bloomfield, Connecticut-based Cigna offered patients a $ 500 prepaid gift card for the transition. The American Medical Association’s House of Delegates voted against the practice shortly after the formulation change was announced.