Health Plan Coverage for Biosimilars Raises Questions

July 17, 2017

Health plans are embracing biosimilars, a new Avalere Health study reveals.  Eighty-one percent of health plans now cover at least one of the two biosimilars currently available in the United States.  But some plan designs raise questions about insurers’ intent.  Do coverage decisions aim to offer patients more treatment options – or drive patients to non-identical drugs based on cost alone?

Avalere Findings

Avalere’s study looked specifically at coverage of:

  • Biosimilar filgrastim, a drug that spurs white blood cell production to help cancer patients fight off infection as they undergo chemotherapy. This biosimilar has been on the market for two years and is now covered by 94 percent of employer-sponsored health plans.
  • Biosimilar infliximab, a drug that treats rheumatoid and psoriatic arthritis, among other conditions. This biosimilar has been on the market for seven months and is now covered by 42 percent of employer-sponsored health plans.

More than 40 percent of the plans have categorized biosimilar filgrastim as “preferred” within their tiered structure of covered drugs.  The preferential placement means the biosimilar will carry a lower out-of-pocket cost, potentially driving patients who currently take the filgrastim biologic to switch.

Options & Interchangeability

Opting for a lower-cost treatment is not, in and of itself, problematic – so long as the two treatments are identical.  But biologics and their biosimilar follow-ons are not identical; they have slight variations that may impact how patients respond to them.  Of particular concern is the potential to affect a patient’s immune system.

The Food and Drug Administration does plan to offer interchangeability status for biosimilars that meet certain criteria – such as producing a near-identical effect to that of the original biologic for any given patient.  But the manufacturer of biosimilar filgrastim has not applied for interchangeability status. In fact, the FDA has not even issued final guidance on what interchangeability status requires.

Yet that doesn’t seem to deter health plans, which overwhelmingly reported to Avalere that biosimilars’ cost led them to cover the drugs.  Providing preferential coverage for a biosimilar, therefore, may be tantamount to encouraging non-medical switching.  This occurs when health plan design compels patients to switch from their current medication to a different, less expensive medication for cost reasons rather than medical factors.  These switches may undermine patients’ treatment and can, research shows, actually result in higher overall health care costs.

Coverage for more treatment options, including biosimilars, is a success for patients.  But health plan design should encourage physicians and patients to continue making treatment decisions based on patients’ best interests, not just their impact on insurers’ bottom line.

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