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New Insights on Payer Policies for Biosimilars

A recently released study on payor practices related to biosimilars was detailed in an article published by the Center for Biosimilars….. and some of the findings are thought provoking.

Here are the highlights from the study:

  • The study identified 1181 coverage decisions for 19 commercially available biosimilars, representing 7 reference products and 28 indications
  • Health plans dictated coverage exclusions or step therapy limitations on biosimilars in 229 (19.4%) of the 1181 coverage decisions
  • Payers were more likely to restrict biosimilar coverage for pediatric populations whereas the reverse was observed for all other categories, including Oncology, for specialty biosimilars.
  • Biosimilar utilization was higher for diseases with US prevalence higher than 1,000,000 cases
  • Biosimilar utilization was higher if the health plan did not contract with 1 of the 3 major pharmacy benefit managers
  • Payers were less likely to enforce restrictions on the biosimilar if:

— the biosimilar was indicated for cancer treatments 

— if the product was the first biosimilar to market

— there were two available biosimilar competitors, and

— could generate annual list price savings of more than $15,000 per patient. 

  • However, payers were most restrictive if the biosimilar did not have a cost-effectiveness measure available.

While many of the findings are confirmatory, the report doesn’t address the underlying dynamics of how rebates affect payer policies over preferred utilization of reference products.


Payers Reveal Most Significant Factors Impacting Biosimilar Coverage Decisions

Jun 29, 2023

Justina Petrullo    AJMC Center for Biosimilars

It was found that cancer treatment, pediatric population, and coverage restriction of reference products were revealed as some of the strongest factors associated with biosimilar coverage decisions by US commercial health plans relative to reference products.

Cancer treatment, pediatric population, and coverage restriction of reference products were discovered as some of the most significant factors associated with biosimilar coverage decisions by commercial health plans in the US relative to their reference products, according to BioDrugs.

CLICK HERE to access the full article


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