Most US Health Plans Cover Biosimilars

A new report shows that most US-based health plans now cover at least 1 of the 2 FDA-approved biosimilars currently available in the marketplace.
Kelly Davio
July 17, 2017
A new report produced by Avalere shows that most US-based health plans cover at least 1 of the 2 FDA-approved biosimilars currently available in the marketplace.

From April 11 to May 1 of 2017, Avalere researchers conducted an online survey of US-based health insurers. Drawing from a panel of health plan personnel, including medical directors, pharmacy directors, and other decision-makers, the researchers arrived at a pool of 50 qualified representatives who spoke on behalf of 45 health plans that cover 183 million individuals in the United States.

The responses collected by the researchers showed that 81% of plans cover at least 1 biosimilar product. When asked to specify the reasons that they have elected to cover biosimilar treatments, the health plan representatives gave the following as key factors in their decision-making:
  • The cost of biosimilars relative to the cost of originator products (cited by 95% of respondents)
  • The efficacy of biosimilar treatments (cited by 80%)
  • The safety of biosimilar treatments (cited by 73%)
  • Existing contracts and portfolio agreements (cited by 53%)
  • The cost of specific biosimilars relative to the cost of other biosimilars (cited by 51%)
  • Other unspecified factors (cited by 4% of respondents) 
About 1% of participants did not specify any factors that had been key to their decisions.

The researchers also examined ways in which health plans cover biosimilar filgrastim (Zarzio) and infliximab (Inflectra). In the 2 years since the launch of biosimilar filgrastim, approximately 94% of employer-sponsored insurance plans have opted to cover the biosimilar product, and 42% have placed it in their preferred-brand tiers, which reduces patients' out-of-pocket costs for filgrastim treatment. This preferred-brand tier placement for the biosimilar is in line with that of its competitors, including Granix, Neulasta, and Neupogen, which have achieved preferred-brand tier placement averaging 45%. Only 6% of plans did not cover biosimilar filgrastim, while 11% of plans, on average, did not cover the competitor products.

The report’s authors suggest that these results demonstrate a growing familiarity with biosimilar products, and that payers may not be waiting for the FDA to give biosimilar products interchangeable status before adopting the products for use.

While the uptake of biosimilar filgrastim by payers may be impressive, an analysis of plans covering infliximab does not demonstrate such strong results; only 7% of plans have placed the product in their preferred-brand tiers, while competitive products including Humira, Orencia, Remicade, and others, have achieved an average of 35% preferred-brand tier placement. Competitor products were, on average, denied coverage by 14% of health plans, 58% of plans did not cover the biosimilar infliximab.

According to the report’s authors, the case of biosimilar infliximab highlights the slow uptake of cost-saving biosimilar products in the US market. The authors state that policy considerations, market factors, and intellectual property-related challenges all currently play a role in curbing the uptake of these products, but point to the recent Supreme Court ruling in the case of Sandoz vs Amgen (which effectively eliminated a 180-day waiting period after FDA approval before a developer could launch a biosimilar product) as a step in the direction of swifter biosimilar uptake.

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