Important Biosimilar Pricing and Reimbursement Updates

March 17, 2023

Dear Valued Members,

Earlier this week, CMS released their updated allowable rates which reflect continued reductions in reimbursement for Avsola, Inflectra, Infliximab, and Renflexis. Below represents the Q2 2023 Medicare reimbursement for each therapy:

Important Note: Majority of Infliximab patients receive their coverage through commercial plans, which have varying reimbursement schedules. As such, we recommend that you compare how changes in ASP impact your reimbursement from each health plan.

The reduction in reimbursement is largely related to therapies attempting to gain formulary coverage and preferred status. This requires manufacturers to pay significant rebates to health plans, which directly reduces ASP.

In response to these changes, Specialty Networks would like to share the ongoing efforts as we continue to advocate on behalf of our members and their patients.  These efforts include collaboration, discussions, and negotiations with manufacturers, distributors/wholesalers, and payers. 

Manufacturer and Distributor Partner Updates 

Our contracting team has been in constant discussions with pharmaceutical manufacturers and our distributor partners to help mitigate the impact of reimbursement declines for our GPO members. At this time, we can share contract updates related to these infliximab products and corresponding net cost recovery impact for Medicare patients.



In the tables below, Net Cost Recovery (pre-mfg. rebate) is calculated as Reimbursement minus Contract Price minus Avg. Distributor Incentives (includes discounts and rebates). Total Net Cost Recovery incorporates the above plus any additional manufacturer rebates.

We will continue to work with manufacturers and distributors to help improve this situation where possible. Please forward this communication to your practice leaders and reach out to us if you have questions and/or if we can assist you in fully comprehending the impact or taking appropriate actions as needed. 

Payers

We recognize there are limitations on what therapies local and/or regional payers will cover and recommend that each member continues to engage with their respective payers to determine coverage limits and voice their concerns regarding the reimbursement challenges.

Specialty Networks is in the process of reaching out to DHPA (Digestive Health Physicians’ Association) to see how we can collectively advocate independent GI physician practices and their patients’ best interests with the payers. 

Independent GI practices are a critical part of healthcare delivery, one that must remain viable, and hence we will continue to advocate on your behalf. We will provide periodic updates as we learn more. Please reach out to us in the meantime with any questions, concerns, and/or suggestions. 

Best Regards,

Specialty Networks GI Team

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