Is It Time to Put Biosimilars First? Core Elements of a Successful Biosimilar Strategy
As specialty drug costs continue to rise, payers and pharmacy benefit managers (PBMs) are increasingly exploring biosimilars as a tool to improve affordability without sacrificing clinical quality. One way to help control specialty spend is to adopt a biosimilar-first strategy for certain drugs. This prioritizes a biosimilar over the reference biologic on formulary when both products are available and clinically appropriate. This approach is grounded in data showing that biosimilars can offer equivalent safety, efficacy, and patient outcomes at a significantly lower cost. Below we outline questions payers can ask their pharmacy partner to learn more about how they approach the rapidly changing biosimilar market.
What Payers Should Ask Their Pharmacy Partners About Their Approach to Biosimilars
1. Is your formulary designed to prioritize lowest net cost options?
Among approved biosimilars, preference should be given to those that offer the strongest combination of clinical quality, member impact, and cost efficiency. Your plan design should be set up to guide utilization toward the lowest net cost option. The lowest net cost option may be the biosimilar, even when taking large rebates into account.
2. How do you ensure seamless substitution where possible?
When a biosimilar earns interchangeable status, it can be substituted for the reference product at the pharmacy level without requiring a new prescription. For products that have not earned interchangeable status, working with both the patient and the physician to educate on options and cost is critical to a seamless transition. Ask how pharmacy-level substitution will be managed without disruption, particularly for patients new to therapy or switching.
3. How is your partner monitoring and responding to the changing market?
With increasing biosimilar competition, constant oversight and reevaluation of these biosimilar market baskets are essential to ensure the best strategy is always being pursued. This allows for rapid changes and the ability to adapt to pricing changes to best align with plan sponsor needs.
4. Is the decision-making entity independent and aligned with your best interests?
To ensure the right therapy is used at the right time, many organizations rely on independent clinical reviews that are not influenced by manufacturer incentives. This independent oversight paired with prescriber engagement and education helps protect both patient outcomes and benefit integrity, while keeping aligned with your best interests.
5. What supports are in place to minimize member out-of-pocket costs?
Biosimilar use can benefit members financially if manufacturers offer copay assistance programs. While not all products offer support, when available these programs can impact patient access by improving affordability. Ask about member assistance programs and how these are managed and tracked for both the member and the plan.
Why This Approach Works For Both Plans and Members
For many plan sponsors, specialty drugs account for more than half of overall pharmacy spend. Biosimilars provide an opportunity to reclaim value in high-cost therapeutic areas while maintaining clinical integrity and patient satisfaction. By asking these questions and demanding transparency and agility from your pharmacy partners, payers can build a tailored, evidence-based biosimilar strategy that optimizes both value and patient experience.
A balanced approach to biosimilars offers affordability, safety, and access. To learn more about SlateRx is helping plans navigate the rapidly changing biosimilar landscape or explore specifically how this would work for your plan, contact inquiries@Slate-Rx.com.
