Health Plans Wary of Biosimilars Despite Potential for Lower Costs | AMCP 2024

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Despite the introduction of biosimilars, brand-name reference products still have the largest market share across the eight therapeutic areas, according to the survey data presented in a poster at the Academy of Managed Care Pharmacy (AMCP) annual meeting in New Orleans.

The survey was conducted by a team from Precision Value and Health, a healthcare consulting firm. Data was based on an October 2023 survey of 25 people from health plan stakeholders. The eight therapeutic areas are rare disease, multiple sclerosis, pulmonary, ophthalmology, inflammatory/autoimmune disorders, diabetes, oncology and oncolytic therapy. According to the poster, the market with the largest number of reference products is currently rare diseases with a 60% product volume rate.

Even though reference products currently dominate the industry, 64% of participants said they “strongly agree” that their organization is confident they can switch from reference products to biosimilars.

So, what’s stopping them ?

The biggest contributing factor leading to a biosimilar restriction is that a PBM has already contracted for a reference product (36%), followed by a reference product being restricted by the plan (32%), according to the survey.

Dan Danielson, M.S.

“Many payers will adopt the PBM formulary for the simple reason that they don't feel they can make a better deal than the PBM and make up the lost rebate revenue they receive,” co-author Dan Danielson, M.S., said in an email interview. “The PBMs have a lot of sway in the market.”

Almost half of the respondents (44%) reported that the biggest operational barrier was the need for pharmacies to contact prescribers.

“The pharmacy having to contact prescribers for a biosimilar prescription likely ranks high as a barrier because it's labor-intensive,” Chris Terrone, M.S., said in an email interview. “Looking forward, the FY 2025 Health and Human Services budget proposal contains a provision that would eliminate the interchangeability designation to which state legislatures have anchored their biosimilar substitution laws. If adopted, it will be interesting to see how the states react.”

A low-wholesale acquisition cost, low-rebate strategy was preferred by a majority of this sample (84%).

Pharmacy benefits were the most likely to lead to a restriction of a biosimilar (64%).

The survey results show that it’s expected that reference product shares will shrink within the next year. The largest decline is expected for inflammatory/autoimmune conditions (64% to 46%).

“As both prescribers and payers get more experience with biosimilars things will change,” Danielson said. “Prescribers need to be confident in the biosimilar, and payers need to gain experience managing these drugs. Additionally, the issue of interchangeability remains a barrier to adoption to both prescribers and payers.”