MEDICAL PHARMACY MANAGEMENT
Biosimilar Reimbursement and Strategy FIGURE 44: BIOSIMILAR MANAGEMENT
FIGURE 45: BIOSIMILAR STEP-THERAPY PROTOCOL
FIGURE 47: BIOSIMILAR STEP-THERAPY CRITERIA
(n=41)
% of payers
% of payers (n=41)
Yes, for new starts only
78%
No
Don’t know
Significant cost differential with biosimilar agent (average 27%)
2
%
Currently Implemented (n=41)
39% 49%
27%
78%
88%
FDA designation of interchangeability
24%
OF PAYERS REIMBURSED BIOSIMILARS THE SAME WAY THEY REIMBURSED ALL MEDICAL BENEFIT DRUGS
OF PAYERS PREFERRED THE BIOSIMILAR OVER THE REFERENCE PRODUCT
Yes, for new starts and current utilizers
42%
Comparable side effect profile and risk of immunogenicity
Implemented for Oncology (n=41)
44%
39%
Provider network acceptance/support of strategy
29%
Member acceptance support of biosimilar product
15%
0%
FIGURE 48: BIOSMILAR PRODUCTS PREFERRED OVER THE REFERENCE PRODUCT NAMED
FIGURE 46: BIOSIMILAR REIMBURSEMENT STRATEGY % of lives (n=168 million)
% of payers (n=32) Medicare model (WAC+6% then ASP+6% of reference product’s ASP)
63%
Other ASP+X%
OF PAYERS SAID PRICING OF BIOSIMILARS WAS MOST IMPACTFUL ON REIMBURSEMENT STRATEGY
AWP-X%
Maximum allowable cost
27%
Comparable drug profit to reference product
SAVINGS WERE NEEDED ON AVERAGE TO WARRANT PREFERENCING A BIOSIMILAR
Other (% billed, capitated, fee schedule)
50%
81%
81% 72%
17%
69%
66%
63%
13%
41%
9% 1% 10%
Neupogen Remicade
Avastin
Epogen/ Procrit
Herceptin
Rituxan
2 0 2 0 / M AG E L L A N R X . CO M / P U B L I C AT I O N S
Neulasta
24