As previously communicated in a Partners in Health Update^SM article, at AmeriHealth we are constantly evaluating our policies and industry trends to identify innovative opportunities to make specialty drugs more affordable without limiting members' access to life-saving medications. One of the ways in which we are doing this is by taking advantage of the growing availability of biosimilars in the United States and developing new strategies on how we use them. These strategies are based on many factors, including drug class, clinical efficacy, continuity of care, and value.

As of May 15, 2020, AmeriHealth has been giving preference to the below biosimilars and has been enforcing these changes on all new starts to treatment since July 1, 2020:

^*Bevacizumab will continue to be covered for ophthalmologic indications, without precertification approval, for all branded products (e.g., Avastin, Mvasi, Zirabev).

Why is this change happening?

These three reference products are commonly used, high-cost specialty drugs. Biosimilars are approved by the U.S. Food & Drug Administration (FDA) as safe, effective treatment options. There are no clinically meaningful differences to branded biologics – like Avastin, Rituxan, and Herceptin – in terms of safety and effectiveness.

How will this affect my patients?

To preserve member continuity of care, AmeriHealth will continue to cover Avastin, Rituxan, and Herceptin for members who currently have precertification approval for those biologics. These members will not be required to transition to a preferred biosimilar.

New coverage requests for bevacizumab, rituximab, and trastuzumab will only be approved for the preferred biosimilars listed above, in accordance with our medical policies. According to the FDA, a biosimilar is a biological product that has no clinically meaningful difference from the existing FDA-approved reference product.¹ All biosimilar products meet the FDA's rigorous standards for approval for the indication(s) described in the product labeling. Once a biosimilar has been approved by the FDA, its safety and effectiveness has been established, just as it has been for the reference product.

Policy updates

AmeriHealth medical policies were updated to reflect new coverage criteria for these preferred biosimilars. The following policies were posted as Notifications on February 13, 2020, and went into effect May 15, 2020:

• #08.00.33o: Trastuzumab (Herceptin^®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta^™)
• #08.00.50u: Rituximab (Rituxan^®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela^®)
• #08.00.66n: Bevacizumab (Avastin^®) and Related Biosimilars for Oncologic Uses

To view these policies, please visit our Medical Policy Portal. AmeriHealth sent targeted letters with more details to network providers affected by this change in June. 

Learn more

If you have any questions related to this information, please review our Oncology biosimilars: Frequently Asked Questions (FAQ). 

¹U.S. Food & Drug Administration. “Biosimilar and Interchangeable Products." 2017. Available from: https://www.fda.gov/drugs/biosimilars/biosimilar-and-interchangeable-products