Biosimilar considerations for payers

Key takeaways:

  • Current biosimilar price dynamics are confusing to the general public
  • Payers should prioritize access and increased competition1
  • Payers need to consider a few different factors when evaluating biosimilars, including1:
    • Product characteristics and evidence
    • Manufacturer supply
    • Dosage form suitability
    • Medical benefit or pharmacy benefit
    • Manufacturer ability to drive market share
    • Economic impact
    • Enhanced product delivery method
  • In order to magnify the benefits of biosimilars, it is recommended that plans adopt biosimilars quickly and encourage their provider base to embrace their use.1

Current biosimilar market dynamics may be confusing and seem to put biosimilars at a perceived disadvantage against their originator biologics. The first biosimilars to enter the market were covered by medical benefit plans, but recently approved biosimilars are covered by pharmacy benefit plans. This has created additional pricing complexities, formulary decisions and contracting challenges, which may result in pharmacy benefit managers (PBMs) not preferring them.

Issues with getting access to formularies are considered one of the largest obstacles to biosimilar adoption in the U.S.2 Some payers may only include a few biosimilars on their formularies. Originator manufacturers who are looking to keep their high market share may offer PBMs list price discounts that deter entry by lower-priced drugs and block patient access to these competitors.3

For biosimilars and, more importantly, patients to benefit, payers must promote access. Increased competition will drive sales prices down and deliver savings to the broader system.1 When biosimilars are listed at parity with the brand biologic on formularies, patients and the healthcare system cannot realize the potential benefits.

Payers should evaluate the incorporation of biosimilars into formularies based on numerous factors, including product characteristics and evidence, manufacturer supply, dosage-form suitability for the covered population, and the economic impact on payers and patients.1,4

Lack of payer support or limiting access to biosimilars will create slower uptake and could have an impact on the development of future biosimilars.

Learn more about the key considerations for biosimilars with each of the following groups.



Specialty Pharmacies

To learn more about the promise of biosimilars, the impact they can create, and our work in this space, visit the following pages:

1. Rifkin; Peck. Biosimilars: Implications for clinical practice. J Oncol Pract 2017;13(9_suppl):24s-31s.
2. Joszt L. Employers face barriers with adopting biosimilars. Formulary Watch. March 1, 2022.
3. Arad N, Staton E, Hamilton-Lopez M, et al. Realizing the benefits of biosimilars: Overcoming rebate walls. Margolis Center for Health Policy. March 9, 2022.
4. Singh SC, Bagnato KM. The economic implications of biosimilars. Am J Manag Care. 2015;21(16 suppl):S331–S340.