On July 1, Aetna launched its new Combined Benefit Management Drug List, effectively moving romosozumab-aqqg (Evenity) and infliximab (Remicade) to pharmacy-only coverage for most fully insured commercial plans.
This change precludes rheumatology practices from obtaining these drugs for buy-and-bill administration, instead requiring acquisition through an approved specialty pharmacy. Certain states are excluded from this formulary change, including Alaska, Arkansas, Georgia, Louisiana, Mississippi, North Dakota, Oklahoma, Rhode Island, Texas and Vermont, due to state laws prohibiting specialty pharmacy requirements. Biosimilar versions of infliximab (Remicade), including infliximab-dyyb (Inflectra), infliximab-axxq (Avsola) and infliximab-abda (Renflexis), remain covered under the medical benefit.
The ACR strongly opposes this change and its harmful impact on rheumatology practices and patients. The ACR sent a letter and met with Aetna leaders to raise concerns about how this change will undermine access to critical office-administered therapies. For most rheumatology practices, accepting specialty pharmacy drugs—a practice also known as “whitebagging”—is not feasible due to the negative impact on practice finances and administrative burden. Policies that require use of specialty pharmacy drugs often necessitate a change in the site of treatment, which then results in higher costs and reduced access for patients.
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