Experts review best practices around plan design that payers and plan sponsors should address as more interchangeable biosimilars potentially enter the market.
Ryan Haumschild, PharmD, MS, MBA: One of the things we talked about is there is a lot of savings for the majority of individuals. When we’re looking at interchangeability, what can health plan sponsors and managed care executives do to address bringing more interchangeable biosimilars to the market? Is there a certain plan design? Is there a certain tiered structure that would incentivize more manufacturers to bring these products forward?
Kimberly C. Chen, DO, MSHLM: Yeah, I think definitely having a biosimilar tier, where the lower tier has more favorable benefits, as well as step therapy, and influence through the formulary decisions related to switching a patient’s treatment. And then [it] goes back to what we talked about earlier about out-of-pocket expenses for the patients and peer incentives with the providers. I think rebates are always tough conversations—there’s a lot more to dissect with that piece, but, to your point, reducing or taking away the co-pay for the patient or some kind of fixed reimbursement fee for the patient. So that way, there is a win-win, again, for the patient as well as the provider.
Jonathan Kay, MD: It’s interesting that with infusible biosimilars, of course, there was no interchange there. But originally the structure, the reimbursement structure from CMS [Centers for Medicare & Medicaid Services] was that the average sales price of the reference product or the biosimilar would be reimbursed plus 6% of the average sales price of the reference product. What that resulted in was no incentive to infuse biosimilars, the added 6% was going to be the same whether you infused a biosimilar or the reference product. But in late 2022, Congress mandated that there be a redesign, and CMS reimburses now 8% of the average sales price of the reference product if you infuse the biosimilar, and only 6% If you infuse the reference product. So that incentive has been realigned to encourage the use of biosimilars.
Ryan Haumschild, PharmD, MS, MBA: Absolutely. Dr [Maia] Kayal, as payers are reviewing the interchangeability, how are they going to prefer these on formularies vs interchangeable and noninterchangeable? And how does that impact the future inclusion of formularies across the board?
Maia Kayal, MD, MS: That’s a great question. Of course, I can only talk about it from [how] I’m perceiving it as a provider, what my patients are telling me and our pharmacists, and what’s being relayed to us, but I can imagine that payers are eager to incorporate interchangeable biosimilars into their formularies because it’s translating into cost savings. And, from our perspective, we’re hoping, again, that those cost savings are passed along to the patient. But I would imagine the incorporation of interchangeability, I’m not sure that there’s necessarily a distinction for the payers, but I’m happy to hear Dr [Kimberly C.] Chen and Dr [Jonathan] Kay’s opinion on this. From the payer’s perspective, is there a distinction? Is it better for it to be an interchangeable biosimilar perhaps, vs a noninterchangeable biosimilar? I can’t imagine that the savings are different in that context. We know that it really just translates into practical implications that the pharmacist can substitute it. But again, it comes down to the payer saving money on this medication that used to be very, very expensive and is now significantly less expensive. So I imagine the payers are excited and eager to incorporate it into their formularies.
Kimberly C. Chen DO, MSHLM: One thing I just want to add, although the savings are for the payer, overall these are the stewards of our medical income economics, so for commercial payers, even though there’s aid for commercial products, and even though there’s savings on the payer side, they’re also influenced by what the employers are paying, and the same thing with Medicare as well as Medicaid, because it always goes back to the society.
Jonathan Kay, MD: So the experience with infusible infliximab biosimilars is such that the introduction of biosimilars has reduced the cost not only of the biosimilar but also the reference product by about 50% compared to 2017 when the first infliximab biosimilar was released. And with the introduction of each new biosimilar, additional market competition has continued to drive the price down. So that now the cost of a 100-mg vial of infliximab is very similar for each of the 3 biosimilars [for] infliximab, which are available as well as the reference product. So biosimilars introduced price competition that drives the cost down not only of the biosimilars but also the reference product, thereby contributing to the savings for the health care system.
Transcript edited for clarity.
This activity is supported by an educational grant from Boehringer Ingelheim.