The ACR recently fought to ensure that three biologics used for arthritis treatments were moved off of the self-administered drug (SAD) list—but the fight isn’t over yet.
Adam Cooper, the ACR’s director of government affairs, says that in October, the Centers for Medicare and Medicaid Services (CMS) directed carriers to again include the certolizumab pegol (Cimzia), abatacept (Orencia), and golimumab (Simponi) in Medicare Part B coverage. Some Medicare Administrative Contractors independently decided earlier this year to move those drugs to the SAD list and terminate Part B coverage.
Although the three drugs have self-injection formulations in addition to those given in physicians’ offices, moving the drugs to the SAD list meant the infused versions of drugs would no longer be available to patients through Medicare Part B. This is a problem, in the ACR’s view, because individual biologics are not equivalent in tolerability, safety, or efficacy, and, for many patients, the self-injected versions may not be as efficacious as IV versions, Cooper says.
The ACR felt it was “clinically inappropriate and unethical” to force patients to discontinue or change biologics that have controlled their disease, especially because switching therapies can cause myriad issues, Cooper adds.
“These bad decisions would have kept many of our patients from accessing or staying on medications that offer them significant improvement in their conditions at more affordable prices,” says ACR President Joseph Flood, MD. “There was no forewarning given by Medicare carriers to rheumatologists, rheumatology health professionals, or patients about the termination in coverage, but I was impressed with how quickly the ACR and others watching out for the welfare of patients were able to learn about threats to the care of people with arthritis.”
Cooper says the ACR, working with the Arthritis Foundation and state rheumatology societies, lobbied CMS, members of Congress, and others to ensure the three biologics were put back under Part B coverage. But he urges rheumatologists to be vigilant in ensuring that carriers do not again attempt to remove the drugs from coverage.
“The battle isn’t over,” he adds.
Richard Quinn is a freelance writer in New Jersey.
