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Centers For Medicare And Medicaid Announce Intent To Reverse Coding Regulation For Avastin

October 28, 2009

Adapted from the U.S. Senate Special Committee on Aging

Today U.S. Senate Special Committee on Aging Chairman Herb Kohl (D-WI) praised the Centers for Medicare and Medicaid (CMS) for announcing its intention to reverse a recent reimbursement coding decision involving Avastin, a popular drug used to effectively treat wet macular degeneration, a leading cause of blindness among seniors and the elderly. Avastin, a cancer-treating drug, is frequently used off-label in small amounts by eye specialists to treat eye disease. Both CMS and the medical community estimate that between 50 and 60 percent of physicians currently use Avastin instead of Lucentis, an alternative treatment. Both drugs are manufactured by Genentech however, Lucentis cost $2,000 a dose roughly 20 times as much as Avastin. Kohl wrote to CMS earlier this month to express his concern over the coding change.

“I'm pleased that CMS heeded the concerns of the medical eye care community and the Aging Committee. Even seniors who have insurance often cannot afford the high co-payments associated with Lucentis,” said Kohl. “Patients should have a choice between these drugs, both of which have been proven effective.”

Medicare spends approximately one billion dollars a year on reimbursements for Lucentis. The recent CMS coding change made it more difficult for ophthalmologists and retinal surgeons to be adequately reimbursed for their Avastin usage. Agency officials intend to return to the original reimbursement coding for off-label use of Avastin, ensuring its continuing availability for those physicians who wish to use it. CMS has said it will implement the reversal of the coding decision on January 1, 2010.

Kohl has been concerned with the issue of Avastin's availability since 2007, when he sent letters to then-CMS Acting Administrator Kerry Weems, then-Food and Drug Administration Commissioner Andrew von Eschenbach, and Genentech, Inc.'s President of Product Development Susan Desmond-Hellman concerning Genentech's proposed plan to limit the availability of its cancer drug Avastin to certain pharmaceutical compounding firms and pharmacies. At the time, some physicians charged that Genentech's intention in limiting Avastin's availability is to boost sales of Lucentis, their far more expensive drug. An October 12, 2007 Wall Street Journal article, entitled “Genentech to Limit Avastin Availability, Use of Cancer Treatment For Eye Ailment Hurts Sales of Targeted Drug,” stated that because Medicare is a large purchaser of Avastin, the cost to taxpayers could be as high as $1 to $3 billion dollars a year if availability of the drug is curbed.

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Some of the content in this section is adapted from other sources, which are clearly identified within each individual item of information.

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