Study Investigates Reasons Commercial Plans Don’t Cover Some Biosimilars

Despite significant potential savings, many commercial plans do not cover biosimilars for many high-price drugs. In a recently published paper in BioDrugs, researchers found several factors underlying why payers have a low coverage preference for biosimilars over name-brand therapeutics. These include plan size, relationships with pharmacy benefit managers (PBMs), and the average yearly savings per patient.

According to Skylar Jeremias, “Among the coverage decisions, biosimilars were covered more restrictively than their reference products 19.4% (n = 229) of the time. Of the 17 health plans assessed, 6 (35.3%) imposed exclusions or step therapy restrictions on biosimilars for less than 10% of all coverage decisions and 5 (29.4%) imposed restrictions on biosimilars for more than 30% of all decisions. Plans were more likely to restrict coverage of biosimilars for pediatric populations (odds ratio [OR], 11.558; 95% CI, 3.906-34.203) and in diseases with a high prevalence in the United States (> 1 million cases; OR, 2.067; 95% CI, 1.060-4.029).”

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(Source: AJMC, April 22^nd, 2023)