Panelists Deliberate Strategies to Enhance Biosimilar Integration in Managed Care Spaces

Speakers at an Academy of Managed Care Pharmacy Nexus session discussed the impact that biosimilars in new specialties will have on managed care stakeholders and market expansion, emphasizing the need for more education efforts and collaboration between departments to ensure the successful integration of new biosimilar products into health systems.

Chelsee Jensen, PharmD, BCPS, senior pharmacy specialist and pharmaceutical formulary manager at Mayo Clinic, provided an overview of the market, current pipeline, and Mayo Clinic’s experience of implementing biosimilars into practice. She explained the overall decrease in the average sale prices of reference drugs because of biosimilars and shared real-world evidence showing that switching from originators to biosimilars is safe and does not raise immunogenicity concerns.

She also talked about the challenges regarding adding biosimilars to electronic health records (EHRs), noting that biosimilars may need to be entered into EHRs in a different way because they have different Healthcare Common Procedure Coding System (HCPCS) codes, which are used to facilitate processing of health insurance claims, than the originators. Additionally, payer preferences for originators and skinny labeling—where biosimilars are only approved for a specific indication rather than all the same indications as the originator (eg, tocilizuamab-sztn is approved for rheumatoid arthritis only)—create additional adoption barriers for biosimilars.

“Some strategies: Collaborate with your payer relations team, understand what your payers are demanding so that you can have a better strategy from a health care institution standpoint; optimize your electronic health record, making biosimilars easy to prescribe; and communicate broadly when there are changes…We need to continue to collaborate, especially as we see some of these products cross the medical and pharmacy benefit,” Jensen recommended.

Prerakkumar Parikh, PharmD, director, specialty clinical solutions at Magellan Rx Management, discussed biosimilar management strategies from the perspective of a pharmacy benefit manager. He also stressed the importance of pharmacists keeping up with individual state laws regarding interchangeability of biosimilars.

To ensure the seamless integration of biosimilars, he suggested that organizations should continue monitoring market share changes and price fluctuations of reference products, educate providers and patients to overcome obstacles like patient hesitancy, ensure the cost-effectiveness of biosimilars are taken into account in coverage decisions, and maintain vigilance over the evolving biosimilar landscape and pricing dynamics.

Thomas Scott Raisor, PharmD, MPH, MBA, BCACP, chief, Pharmacy and Therapeutics Section, Defense Health Agency, outlined how biosimilar management has affected patients covered under TRICARE, which is the Department of Defense’s pharmacy benefit program.

Raisor noted that TRICARE’s spending on biologics is high despite these products having overall low utilization across the program. He outlined their approach of considering biosimilars as safe alternatives, such as using regular reviews and step therapy policies that require treatment-naïve patients to be treated with a biosimilar before the reference product. Raisor discussed balancing product choice, pricing and market responsiveness, and the value of prescriber and patient input in treatment decisions.

Annie Schuster, PharmD, FAMCP, senior director of clinical pharmacy programs at Cigna Healthcare, discussed the implications of biosimilars from the perspective of a health insurance company that works with Medicare Advantage and Part D plans. She delved into a range of topics:

• CMS options for managing biosimilars across both medical and pharmacy benefits
• The utilization of formulary strategies like preferred tier placement and cost-sharing reductions to encourage biosimilar usage
• The importance of considering high- and low-concentration products and anticipating future Part D dynamics when covering adalimumab biosimilars
• The multifaceted factors that influence biosimilar uptake within plans
• The significance of educating prescribers and pharmacists to elucidate the costs and benefits for increased biosimilar acceptance.

Schuster concluded, “We've learned that it's imperative to have a continued focus in this dynamic environment to ensure we're providing access and choice to safe, effective, high-quality, affordable medications for our members…. Biosimilars are requiring us to continuously reforecast as the influencing factors change over time. It’s so important for those involved in the strategy to purposefully coordinate and educate all internal and external stakeholders.”