Midwest Business Group on Health Issues Call to Action on Biosimilars

In a report on the role of biosimilars in transforming pharmacy benefits, the Midwest Business Group on Health (MBGH) has issued a call to action for employers to increase employee access to biosimilars—and achieve savings.

“If employers are serious about driving down costs, while ensuring their members have access to therapies that treat complex chronic, life threatening, and rare medical conditions, this is the time to act on the use of biosimilars,” said the authors.

The report listed 13 steps for employers to take that address several barriers to biosimilar uptake including lack of utilization incentives, prior authorization (PA), and lack of biosimilar education.

Formulary Requests

A major barrier for employers that want to increase usage for biosimilars within their organizations is formulary lists, which restrict patients’ choice of drugs to the ones pharmacy benefit managers (PBMs) and payers want them to use. MBGH recommends that employers send the FDA’s list of approved biosimilars to PBMs and payers and initiate discussions on how to adopt them.

In addition, the MGBH recommended that, through negotiations with carriers, biosimilars be made available through the pharmacy benefit, not just through the medical plan. They also advised that if a biosimilar is available through the pharmacy benefit, employers “talk to your PBM and ensure proper medication therapy management measures are in place.”

Employers should also insist that biosimilars be authorized for all indications of the reference product, as some biosimilars may not have received a specific FDA approval for every indication of the originator. The FDA, in granting biosimilars approval, implicitly certifies that they are just as effective for all approved indications of the reference product.

Aligning Incentives

The MGBH said PA should be managed, ideally, through an independent pharmacy and therapeutics committee to avoid conflicts of interest caused by financial incentives to approve one drug over another.

For some employers, managing PAs through independent entities may not be feasible. In that case, employers should ensure that appropriate PAs or step therapy protocols are established for each biosimilar, the MBGH said.

Co-pays and coinsurance requirements can discourage use of costly biologics, so the MGBH recommended that employers improve the incentive for using biosimilars by reducing out-of-pocket costs when these are administered. In addition, it’s important to ask carriers about educating providers about biosimilars and incentivize them to prescribe the cheapest, most effective drug first.

MBGH recommended that contracts with carriers and PBMs be written so that all rebates are passed through to employers and plan activity can be audited.

Plan Inclusions

In addition to incentivizing and educating providers to prescribe biosimilars, MBGH recommended that employers consider using step therapy to ensure that biosimilars are used first for treatment-naïve patients before trying the more expensive reference product.

For employees who already are being administered a reference product, the report suggested they be “grandfathered in” or allowed exceptions—based on consultation with a physician regarding biosimilar use. This is because patients whose conditions are well managed with an originator drug may be nervous about a switch.

“The physician/patient relationship is key in determining whether nonmedical switching is appropriate with each involved in the discussion,” MGBH said. Employers should also consider plans for appropriate transition of grandfathered employees at a later date.

The report added that employers should consider having employees undergo pharmacogenetic testing prior to use of biosimilar agents. Pharmacogenetic testing provides a portrait of an individual’s likely response to the biologic agent, including any potential adverse reactions.

Health plans also should include utilization tracking based on drug class in medical and pharmacy data to determine where the greatest opportunities to increase biosimilar usage exist, the business group said.

Cheryl Larson, president and CEO of MBGH, is one of the authors of the report and spoke recently with The Center for Biosimilars^® about employer concerns and the battle to get more biosimilars onto formulary and realize the savings that these products have to offer.

Reference

Larson C, Giambalvo D. Transforming pharmacy benefits: the role of biosimilars. Midwest Business Group on Health. 2020. Accessed August 28, 2020. https://higherlogicdownload.s3.amazonaws.com/MBGH/4f7f512a-e946-4060-9575-b27c65545cb8/UploadedImages/Specialty%20Pharmacy/2020/MBGH_Biosimilars_Report_Final-b.pdf