The Health Ministry recently removed bevacizumab and cetuximab from coverage in the latest issuance of the national formulary, which lists drugs that can be procured and covered by the JKN, on the grounds that they had limited effectiveness for curing patients while they cost a lot of money to the scheme.    

Evie Yulin, the biopharma director of PT Merck, a subsidiary of the German pharmaceutical company Merck that produces cetuximab, said that although the company respected the government’s decision, it regretted that the ministry did not involve the industry in the discussion before issuing such an important policy.

She said cetuximab's participation in JKN as part of the therapy for colon cancer contributed 50 percent of Merck’s cancer drug business the country.

“We hope that we get the opportunity to provide insight to the government and relevant parties regarding the provision of alternative methods of financing and the selection of target patients so that cancer patients can have their right to get affordable treatment,” Evie told The Jakarta Post on Wednesday.

The company received a permit to distribute cetuximab from the Food and Drug Monitoring Agency (BPOM) in 2007 and it has since been used for targeted therapy in colorectal cancer treatment.

The ministry and the Health Care and Social Security Agency (BPJS Kesehatan) have started to cut back drug coverage and treatments in the past year in their efforts to cut the perpetual deficit experienced by the state insurance, which was estimated to surpass Rp 10 trillion in 2018.  

The state insurer reported that it had to pay almost Rp 3 trillion only for claims related to cancer drug treatments last year, which was the second largest amount after that for treatments for cardiovascular treatments, which was Rp 9.4 trillion.

Last year, the state insurer had tried to remove coverage for trastuzumab, a breast cancer drug, but the ministry ordered the agency to resume it after a patient filed a lawsuit.

The latest decision to delist another two cancer drugs, which is to be effective on March 1, was based on the ministry’s Health Technology Assessment (HTA) that found the drugs to be less cost effective. The BPJS Kesehatan has suggested patients use alternatives of the drugs available in the national formulary.    

Ait-Allah Mejri, the president director of PT Roche Indonesia, a subsidiary of a Swiss pharmaceutical company, Roche, which produces trastuzumab and bevacizumab, said the company was “very disappointed” with the decision that has failed “to safeguard the interests of patients”. 

He also questioned the HTA results that concluded they failed to meet the needs of cancer patients.  

“Even if bevacizumab was provided free of charge, chemotherapy treatment alone would not achieve the cost-effectiveness threshold that is currently in place. [..] While we understand the pressure around budgets, it is ultimately patients who suffer. We remain firmly committed to work together with all parties to make bevacizumab available in Indonesia,” Mejri said. 

Roche attained a permit to  distribute bevacizumab in 2006 and the drug had been covered by the now defunct state-owned health insurance firm PT Askes in 2008 and later by the JKN.

The head of a health insurance policy working group at the National Team for the Acceleration of Poverty Alleviation, Prastuti Soewondo, said it was normal for the companies to resist the new regulation as it makes them lose their markets. 

However, Prastuti said he believes that the nation is currently fixing the health care system and removing or adding medicine to the national formulary to achieve the rational use of medicine.

“The mistake we made from the beginning was we had these benefit packages that were too comprehensive and beyond our ability to cover with the relatively small premium contributions. We also did not consider cost effectiveness and fiscal reliability when compiling the drug items in the national formulary, but we are fixing it now,” she said.

Prastuti also said that the ministry had carried out the HTA carefully before issuing the national formulary.

“I have to make it clear that these two medicines, bevacizumab and cetuximab, are not cost effective, so the issue here is not about the budget,” she said.