Top 3 factors in biosimilar coverage


An Avalere study has interesting findings about payer acceptance of biosimilars.

Most health plans are covering at least one of the two biosimilar products currently on the market, according to a new study.

Based on a national survey of health insurers by Avalere, 81% of plans report they are covering a biosimilar product. Nearly all payers indicate that a biosimilar’s cost relative to the originator is a key decision-making factor for determining coverage. In addition to costs compared to the originator, health insurers cite efficacy and safety of the biosimilar as important factors for coverage decisions.

Using an online platform for collecting survey responses, Avalere surveyed U.S.-based health plans between April 11, 2017 and May 1, 2017, to ask what were the important factors in covering biosimilars. Respondents were recruited from a panel of health plan personnel and then screened to determine eligibility to participate, requiring that they be a medical director, pharmacy director or have a similar role. They were also required to be a decision maker or influencer in their health plan. A total of 50 qualified representatives participated in the survey, representing 45 different health plans. Health plans included in the study represent 183 million of the covered lives in the United States.

To supplement the survey findings, Avalere experts reviewed how insurance plans cover Zarxio, ((filgrastim-sndz) the first biosimilar product approved in the United States, and Inflectra (infliximab-dyyb).

Zarxio is biosimilar to Neupogen (filgrastim), and is covered by 94% of employer-sponsored plans, according to the study. Inflectra, a biosimilar to Remicade (infliximab), is covered by 42% of employer-sponsored plans.

Choe “Plans are also placing biosimilars on their preferred brand tiers at rates in line with the competitor products,” says Sung Hee Choe, vice president at Avalere. “Placement on this tier reduces the out-of-pocket costs for patients compared to drugs on non-preferred brand or specialty tiers.”

The top three factors chosen by health plans in covering biosimilars were:

  • Cost relative to originator product (95%)

  • Efficacy of the biosimilar (80%)

  • Safety of the biosimilar (73%).

“Health plans are becoming increasingly comfortable with biosimilar products,” according to Choe. “This is despite the two biosimilars on the market not having interchangeability status from the FDA.”

There are several obstacles to biosimilar market growth, according to Avalere, including the complexity of biosimilar development, uncertain provider and patient acceptance, and intellectual property rights. One such barrier was recently addressed with the recent Supreme Court decision that will allow a biosimilar to launch sooner than 180 days after approval. Continuing to overcome these barriers will be key to creating a robust biosimilars market.



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