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The Role of Insurance Companies and PBMs on Biosimilar Access


Ali McBride, PharmD, MS, BCOP, FAzPA, FASHP: Will PMBs [pharmacy benefit managers] and insurance companies be the key drivers for implementation of biosimilars? I think they will to some extent, but they also have a larger partnership with the healthcare institutions and physicians. We’ll see that a lot of biosimilars are covered by the payers at this point in time. But also don’t forget, we’re under some alternative payment models right now called OCM—Oncology Care Model. That’s transitioning to a new model shortly. We just saw it open up recently with a potentially new concept as well.

When we’re taking a look at OCM, which is thought to derive a lower total cost of care with equal safety and outcomes, in those cases the Oncology Care Model and subsequent models that may occur will really be to drive down total cost of care. How do you do that? Biosimilars. By reducing total cost of care under OCM, or alternative payment models, just like that—as we’re seeing some payers participate with this—you can drive down these total costs of care. As such, you reduce the overall healthcare burden. That healthcare burden we’ve seen in the US continues to increase every year in cost. Right? Sometimes outpacing our GDP [gross domestic product] by tens upon tens of percentiles.

Again, the utilization of biosimilars in this space will only drive down cost. It will decrease overall US healthcare spending, but it may also decrease our US healthcare spending in our patients on a Medicare Part D and B—an area often overlooked because we’re talking about private payers. But as patients who are getting older have a higher risk of cancer, in those cases we can drive down those costs under those different CMS models, or Centers for Medicare and Medicaid Services models, in the older population, looking at Medicare.

That is an untouched area to drive down costs. Hopefully, as we see this increasing burden, increasing discussion on costs and those models, utilizing biosimilars will drive down the cost in the opposite way, even amid the advent of newer therapies for treatment in cancer populations.

Kashyap Patel, MD: The insurance companies and PBMs are somewhat challenges between physician and patient, and one of the commercial insurances had a policy that was announced effective July 1 that we had to use the reference biologic compound. I don’t know how they came to that. But it probably was some sort of contractual arrangement between the manufacturer, the PBM, and the insurance.

And it does become difficult because we want to work with the patients. We do not want insurance company or the PBMs to come between us and patients. Particularly when we are using less expensive, equally effective drugs, I don’t see any rationale of why they should be tying our hands down. So it does become a problem.

Fortunately, Medicare, which is one of the biggest payers in the country, has no restriction of what we can use and what we cannot use. So we are still able to support over half the patients. With the other half of patients, we need to be worried about PBMs and insurance companies dictating how we can treat them.

Ali McBride, PharmD, MS, BCOP, FAzPA, FASHP: There’s a lot of discussion of co-pays in private insurances and also government-based insurances, as we see in CMS cases too. You can have Medicare Part D and also Medicare Part B. That’s primarily looking at our Medicare population. Sometimes patients are eligible for both Medicare and Medicaid and also some variations out there as well.

Right now the Medicaid-Medicare population, really looking at Medicare, there’s a certain deductible amount: 20%. If you have a supplemental, that gets rid of it. However, when you’re looking at Medicare Part D, if you’re buying through that, there will be a higher percentage on that population, as well as the fact that you may not have supplemental insurance. Currently there are some potential laws that are coming through the federal regulation, which are looking to decrease or get rid of any co-pays if you’re using a biosimilar. This will definitely move a quick direction implication of biosimilars in that patient population.

For our private-based preference, or private-based entities for insurance, in these cases that will all be dependent on what the PBM dictates for actually co-pays or co-shares on those costs, as well as any patient assistance or free-drug capability. I think there will be some variations because when you’re going to a government-based insurance, you can’t get some of those co-pay cards. You can’t get some of that manufacturer assistance. In those cases, you’re kind of dependent on foundation assistance. When it goes to our private payers, you are eligible for those, so you will have some variations. Unless we see some litigation occurring, and with new laws that are developed, there will be some different facets for biosimilars and co-pays as well.

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