Win for IBD patient care: BCBS reversed its policy on biologics.

Blue Cross Blue Shield (BCBS) will not move forward with changes to its medical policy guideline “Infliximab Biosimilar Step Therapy Requirements” (Policy Number RX501.051), after ASGE, ACG, AGA and NASPGHAN expressed concerns with proposed changes that would have limited preferred status drugs to Avsola and Inflectra — biosimilars that often leave physician practices “underwater” because their acquisition costs typically exceed reimbursement rates.

The proposed policy would have applied to BCBS plans in IL, MT, NM, OK and TX. BCBS says the June 1, 2024 version of the policy will remain in effect, which gives preferred status to Avsola, Inflectra, Infliximab (unbranded), and Remicade.

In a Nov. 5 letter to BCBS, the GI societies warned that if Avsola and Infectra were the only biologics with preferred status, physicians may have no choice but to refer BCBS patients to hospitals for infusions, resulting in higher patient out-of-pocket costs and potential delays in care.

The GI societies also warned that preferred drug utilization management tools inhibit patient access to prescribed care. Formulary changes are occurring with increasing frequency and result in non-medical switching at the expense of IBD patients, even when they are stable on existing therapy. The letter stated that non-medical switching poses a particular risk to pediatric patients, who have a longer lifetime burden of disease and often more severe disease that impacts how they will respond to a biologic agent.

The GI societies remain vigilant against policies that are detrimental to the delivery of physician recommended GI care and that expose physicians to financial risk or added administrative burden.