Over the past several months, the ACR has met with commercial health insurance payers and the Centers for Medicare & Medicaid Services to provide feedback on formulary requirements that would leave practices under water when treating patients with biosimilars infliximab-axxq (Avsola) or infliximab-dyyb (Inflectra). Specifically, the ACR has raised concerns about payer formularies mandating use of these specific biosimilars despite reimbursement falling below acquisition cost for many independently owned rheumatology practices.
Several payers have responded to the ACR outreach and updated their fee schedules, increasing reimbursement for these drugs. Blue Cross NC is the most recent payer to adjust rates, implementing a temporary increase effective May 1, 2024, through March 31, 2025. Blue Cross NC joins UnitedHealthcare and Aetna, which implemented similar increases in April 2024 and July 2023, respectively.
ACR members are encouraged to contact [email protected] with feedback on the impact of the recent rate adjustments or to share information about other commercial payers with underwater rates.
