Insurance Restrictions
Although the IV iron formulations are considered similarly safe and effective, there is another powerful factor that determines which formulation patients may get: insurance coverage.
IV iron infusions are expensive products. Ferric carboxymaltose, for example, has a wholesale acquisition cost of $1,140 per vial.
In 2017, a Kaiser Health News analysis of private insurance claims found that private health plans paid an average of $4,316 per visit for an infusion of ferric carboxymaltose.7 Ferumoxytol was the next most expensive infusion drug, at $3,087 per visit. Given the costs, many insurance companies require that patients demonstrate an intolerance to oral iron before trying IV iron.
The Kaiser Health News investigation suggested that there was a good reason for this stipulation: The use of newer and pricier IV iron formulations spiked in recent years, making up more than half of IV iron infusions in 2017, up from fewer than one-third 3 years earlier. Consequently, use of cheaper, older formulations has fallen dramatically.
Experts told ASH Clinical News that insurance companies impose other restrictions on which formulations of IV iron patients can receive and under what circumstances, some of which they do not fully understand.
For example, Dr. Auerbach said that Aetna and United Health Care require providers to use LMW iron dextran, the least expensive formulation. “It’s less convenient for our nurses because it takes an hour to infuse, but I don’t really blame [the insurance companies] for that, so we just use it,†he commented.
But a pharmacist, who requested anonymity because she was not authorized by the pharmacy leaders to speak to the media, said this does not tell the whole story. Iron dextran is the least expensive drug on its own, but, she said, that does not account for the cost of “chair time†at the infusion center. The longer a patient remains at the center, the more expensive the treatment becomes because of facility and labor fees. Patients who receive LMW iron dextran must receive a test dose and be monitored before receiving their full dose, she explained. “After adding in the cost of the time, the cost is probably about the same [compared to some other formulations].â€
The pharmacist added that shortly before the start of the pandemic, her group started receiving denials for ferumoxytol and ferric carboxymaltose from both Aetna and United Health Care. “They have stated that patients have to be intolerant to iron dextran, iron gluconate, and iron sucrose, before approving the use of the other two IV iron options.â€
This presents “a real inconvenience to patients,†she explained, “because now we either use iron dextran, which means that they literally stay in the infusion clinic for at least 3 hours, or we use ferric gluconate, which means that they have to come back four times. If we use iron sucrose, they have to come back five times.†The COVID-19 pandemic has further complicated the need for multiple trips to the infusion center.
“Since we think [the IV iron formulations] are all safe and they’re all equally efficacious,†Dr. Achebe said, “generally, we choose formulations based on the patients.â€