Tighter coverage restrictions certain for costly treatments

November 1, 2011
Tracey Walker
Tracey Walker

She is senior editor of Managed Healthcare Executive.

Blue Shield California will no longer pay for the use of Avastin to treat metastatic breast cancer.

NATIONAL REPORTS- Blue Shield of California will no longer pay for the use of Avastin (bevacizumab) to treat metastatic breast cancer, according to The New York Times.

In a followup statement, Blue Shield said a panel of oncology experts will review each new treatment request individually, and Avastin will be covered if the panel determines it to be medically necessary. The plan will continue to cover Avastin for advanced breast cancer for any covered member currently under treatment with Avastin.

Non-coverage trends are growing, according to Randy Vogenberg, PhD, principal at the Institute for Integrated Healthcare in Sharon, Mass., and executive director of the Biologic Access & Finance program at The Jefferson School of Population Health in Philadelphia.

Once reimbursement changes like this occur, more restrictions can follow in less-obvious areas of medication or medical care, adds Vogenberg.

Blue Shield is said to be the first large insurance company to end payments since FDA's Oncologic Drugs Advisory Committee recommended in June that FDA withdraw its approval of Avastin in combination with paclitaxel chemotherapy for previously untreated (first-line) HER2-negative metastatic breast cancer. The committee's recommendation is not the final decision and Avastin plus paclitaxel is still FDA approved for women with HER2-negative metastatic breast cancer.

The FDA Commissioner will make the final decision on whether Avastin should remain approved for metastatic breast cancer. FDA has not announced when that will happen.