Lowering Patient Drug Costs with Biosimilars Can Happen When the Right Teams Come Together


Pharmacy benefit managers can help health plans understand when to best leverage and align to biosimilars and other cost-effective treatments.

Innovation isn’t always guaranteed to succeed. High-potential ideas sometimes don’t take off like we thought they would. And in recent years, many of us in the pharmacy and medical space have wondered if biosimilars would be in that category. But early evidence shows these medications hold great promise when it comes to lowering costs and providing effective therapies.

Biosimilars are biologic products proven to have a highly similar effect to Food and Drug Administration (FDA) approved products but without the additional cost that comes with a reference brand drug. According IQVIA, the U.S. healthcare system saved $338 billion in 2020 prescribing generic drugs and biosimilars. And biosimilars have the potential to help address one of today’s health care crises: rising drug costs.

At Prime Therapeutics, we have the unique viewpoint afforded to pharmacy benefit managers (PBMs): In partnering with health plans, we are able to analyze a high volume of member data to understand how to recommend the best care at the best cost.

We see a great deal of opportunity to obtain market-leading savings for clients that begin to adopt biosimilars and lower net cost options rather than high-cost reference brand biologics, which can in turn help hold down premium costs for members.

And in the last year, we’ve begun to see biosimilar use increase in the oncology and autoimmune categories.

So, one would think drug costs will immediately fall, right?

Unfortunately, it’s not so simple. Managing both pharmacy and medical drug spend is a challenge because of a lack of alignment between key members of a patient’s care team: pharmacies, health plans and providers.

That’s what the Prime team set out to address with the introduction of MedDrive™, a program launched in 2021 that uses advanced analytics to help health plans uncover medical opportunities to reduce current drug spend.

Three MedDrive oncology biosimilar recommendations — bevacizumab (the originator brand-name drug is Avastin), trastuzumab (Herceptin) and rituximab (Rituxan) — have already reduced per member per month (PMPM) costs by 26% over the past year.

Our data has shown the valuable role PBMs can play in a patient’s care team, supporting both patients and health care providers in selecting clinically appropriate and cost-effective drugs for preferred coverage.

We believe that these types of partnerships are at the heart of opportunities for biosimilar growth in the future. PBMs can help health plans understand when to best leverage and align to biosimilars and other cost-effective treatments, bringing key parts of the health care industry together – including payers, providers, specialty pharmacies and manufacturers. Through collaboration, the team can help ensure biosimilars are accepted and used as equally safe and effective treatments so people can benefit from the most appropriate drug at the lowest net cost available.

Alone, biosimilars won’t be a silver bullet to help drive cost savings for health plans and reduced premiums for members. But I look forward to seeing what we can do together.

This article was originally published on Managed Healthcare Executive.

Kelly McGrail-Pokuta is vice president of trade relations and strategy, chief trade relations offficer, at Prime Therapeutics, a pharmacy benefits manager for Blues plans that is in headquartered in suburban Minneapolis.

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