Plan sponsors leverage several tools to ensure members have access to safe and effective specialty medications, while simultaneously managing rising drug costs. The emergence of biosimilars will provide additional opportunities for savings, but careful planning is required to capture them.
Here are three strategies that can help maximize the value of these lower cost, clinically equivalent alternatives to expensive biologic drugs.
1. Optimize plan design and formulary management
To increase awareness and adoption of biosimilars, plan sponsors should ensure the payment provisions of their prescription drug benefits are built to capitalize on the lowest net cost options.
- Plan design – Drug tiering, a common pharmacy benefit plan design, rewards patients with a lower copay if they use a lower-cost or preferred drug. In a traditional three-tier design, generics fall in the first tier, with preferred brands in the second and non-preferred brands in the third. However, as more biosimilars come to market, plan designs with four to eight tiers should become more prevalent.
- Drug formulary management – As the specialty drug landscape evolves, it’s critical for plan sponsors to stay up-to-date on biosimilar developments so they can manage their formularies accordingly. A strong formulary management strategy can also aid price negotiations with drug manufacturers by driving more competitive pricing.
2. Integrate the full range of specialty cost control solutions
Many of the same cost control techniques plan sponsors already rely on to drive better health outcomes and lower costs can also facilitate the most appropriate and cost effective use of biosimilars. Some of these controls may include:
- Prior authorization (PA) – This utilization management tool helps guide members and providers to drugs that are most effective for a particular condition and most appropriate for the individual patient. It’s imperative that biosimilars be included in the PA process as an alternative to more expensive biologics. However, the final determination on which drug is right for a patient should be made using clinical criteria.
- Step therapy – This strategy requires a patient to try a lower cost therapy and see if it’s effective before they can qualify for a more expensive therapy. A recent study of commercial and public payer data showed that UM policies including step therapy contributed to a sizable movement toward biosimilar adoption.
- Medical drug management – The goal of this approach is to mitigate the administrative challenges posed by specialty drugs managed under the medical benefit so plan sponsors can improve visibility across benefits and drive more savings. Data analytics tools can also be applied as part of a medical drug management program to determine under which benefit—pharmacy or medical—a biosimilar should be covered for maximum cost effectiveness.
- Site of care redirection – There is often a substantial cost difference among facilities that dispense the same specialty drug. Because of this, steering members towards the optimal care setting is crucial—especially with biologics and biosimilars, which typically require administration by injection or infusion under the supervision of a medical professional.
3. Provide educational resources to members and providers
Some providers and patients are still new to biosimilars, while others might be misinformed about their safety, efficacy and possible financial benefit. Plan sponsors can overcome these challenges by sharing evidence-based educational materials on biosimilars with these parties, in addition to regular updates on how biosimilars impact benefit options.
- Third-party educational resources – The U.S. Food & Drug Administration offers a variety of member and provider educational materials on biosimilars, including a stakeholder toolkit designed to help prescribers and patients have more productive discussions about these medications.
- Proactive outreach – Plan sponsors should rely on their specialty pharmacy partner to help them deploy a multichannel approach for communicating with members and providers about biosimilars. This can include a complementary mix of channels spanning phone, email, web and print to highlight updates on these drugs and their potential savings.
An experienced specialty pharmacy partner can help connect the dots
While biosimilar approval and adoption have been slow, they’re gaining momentum. To prepare for the road ahead, plan sponsors should work closely with their specialty partner to develop a go-forward drug strategy that effectively accounts for these potentially game-changing therapies. By doing so, they can potentially reallocate the savings generated by biosimilars to other areas of care and provide more cost effective alternatives to patients who may not have been able to afford them before.
Evernorth is uniquely positioned to help with this. Watch the video above to learn more about our history of leadership creating a pathway for biosimilars and driving to the lowest net cost therapy.
