After pressure from Congress and concern from doctors, the Centers for Medicare and Medicaid now plans to reverse recently enacted reimbursement coding for Avastin, which is used to treat wet macular degeneration, a leading cause of blindness among seniors and the elderly. The drug, you may recall, is often used off-label in small amounts to treat the eye disease.
Here's the rub: Avastin is made by Genentech, which also sells Lucentis, a much more expensive drug approved by the FDA to combat the same problem. But, as noted by Herb Kohl, a Wisconsin Democrat on the Senate Special Committee on Aging, anywhere from 50 percent to 60 percent of docs use Avastin instead of Lucentis. Why? Lucentis cost $2,000 a dose versus about $50 for Avastin.
Medicare recently introduced a new payment code that cut payments to docs - ophthalmologists and retinal surgeons - for small doses of Avastin, a move that could prompt them to switch to Lucentis. Kohl has been after CMS to reverse its coding (see his Oct. 9 letter here), because the higher-priced Lucentis may cost Medicare an extra $3 billion or so a year, and seniors may have to cough up additional copayments that he called "unaffordable." The CMS reversal takes effect on Jan. 1, The Wall Street Journal notes.
"Even seniors who have insurance often cannot afford the high co-payments associated with Lucentis,” Kohl says in a statement today. “Patients should have a choice between these drugs, both of which have been proven effective.”