Biosimilar Filgrastim Would Lower Medicare Out-of-Pocket Expenses

Gary Puckrein, PhD

Out-of-pocket expenditures are substantially less among Medicare beneficiaries with breast cancer undergoing chemotherapy who receive prophylaxis for febrile neutropenia with a filgrastim biosimilar (filgrastim-sndz; Zarxio) as opposed to the reference product.

This was the finding from a simulation analysis derived from more than 1600 claims for the biosimilar filgrastim-sndz or the branded reference filgrastim. In the simulation, when extrapolated to 100,000 beneficiaries (1 million claims), the model estimated a potential out-of-pocket saving of approximately $9.5 million for Medicare beneficiaries administered filgrastim-sndz over reference filgrastim. In addition, Medicare saw reduced payments of $32.9 million, according to research by Gary Puckrein, PhD, and colleagues, who presented their data in a poster at the 2018 San Antonio Breast Cancer Symposium.

Filgrastim-sndz was the first filgrastim biosimilar approved by the FDA, entering the US market in 2015. For this simulation, ICD-10 codes were used to identify breast cancer patients, and HCPCS codes were used to identify those treated with filgrastim-sndz or reference filgrastim. Extracted claims from the 2016 Medicare Limited Data Set were used to populate the model.

The investigators, led by Puckrein, president and chief executive officer, National Minority Quality Forum, Washington, DC, extracted 233 claims for 300 µg of filgrastim-sndz (average price, $244.94), and 383 claims for 480 µg of filgrastim-sndz (average price, $421.15). The total number of claims for filgrastim-sndz, therefore, was 616, with a weighted average price of $362.79.

Also extracted were 380 claims for 300 µg of reference filgrastim (average price, $283.92), and 684 claims for 480 µg of reference filgrastim (average price, $478.32), for a total of 1064 claims for reference filgrastim, with a weighted average price of $406.86.

Medicare’s payment calculation worksheet was used to calculate the average Medicare payment to the provider and the average beneficiary out-of-pocket responsibility per claim for either product. Beneficiaries were assumed to pay the provider 20% coinsurance; in the case of a secondary payer, the payment to the provider was 20% minus payment by the secondary provider.

Physicians we reimbursed by Medicare at 80% of the allowed charge for either product, with a 2% reduction calculated for prescriptions written during the sequestration period that began in 2013.

Total payment to the provider, therefore, was considered to be $221 for 300 µg of filgrastim-sndz and $380 for 480 µg of filgstrim-sndz, and $257 for 300 µg of reference filgrastim and $433 for 480 µg of reference filgstrim.

The weighted average saving to Medicare for the use of filgrastim-sndz over the reference product was $32.87 per claim, reflecting the Medicare weighted average payments to providers of $284.06 and $316.93 per claim, respectively.

“By weighted average, a beneficiary’s out-of-pocket responsibility for filgrastim-sndz was lower than that for reference filgrastim ($72.94 versus $82.45), creating a weighted average cost saving per claim of $9.51,” the investigators concluded in their poster. “Extrapolated to 100,000 beneficiaries (1 million claims), the overall out-of-pocket saving for administration of filgrastim-sndz rather than reference filgrastim would be around $9.5 million.”

Puckrein G, Xu L, Ryan A, et al. Potential Medicare beneficiary out-of-pocket cost reductions through use of biosimilar filgrastim-sndz over reference filgrastim among breast cancer patients: A simulation model analysis.