What do payers see as critical to unlocking the stalled US biosimilar sector?
How do payers view the trends in the sluggish US biosimilar market and what initiatives do they want from pharma? Originator companies are fiercely defending their brands which has slowed new product introductions and limited clinicians' ability to build prescribing confidence with biosimilar products. While payers remain upbeat about biosimilars they are looking to pharma to deliver the evidence of safety and utility to educate and support a cautious clinical community.
What strategies are payers using to drive biosimilar usage? Will the FDA's guidelines on interchangeability accelerate the market? Why is competition essential in the biosimilar space? To really understand how US payers see the biosimilar market playing out turn to Biosimilars: US Payer Insights (2019). This detailed report, based on in-depth interviews with experienced US payers, reveals their insights on current trends, future developments and the practical steps pharma can take now.
Payers tackle key questions such as
- How confident are payers in reimbursing biosimilars and has this level of confidence changed over the last 12 months?
- What are the best methods of educating key stakeholders about biosimilars and what needs to be the focus of such campaigns?
- Are biosimilar developers making enough effort to understand payer goals and objectives and what can they do to improve their engagement?
- What are the arguments for non-medical switching from branded to biosimilar products?
- How much of a concern to payers is the 'rebate trap' and have anxieties increased over the last 12 months?
- In terms of real world evidence what are payers looking for and how influential is it?
- What do payers think of pharmacy-level substitution of branded biologics for a biosimilar of the same molecule and why might this not be possible countrywide?
Includes supportive case studies
- Amgen's controversial "Circle the Suffix" campaign
- The Biosimilars Council and the APhA biosimilar education
- Boehringer Ingelheim's content-driven
- Learning from the UK – NHS resources for the launch of Humira biosimilars
- The PCMA's "Protect the Savings" campaign
- How the success of Zarxio has improved confidence in biosimilars
- Is the FDA's interchangeability requirement too stringent?
- PBMs' unfair practices and their effect on biosimilar developers
- Payer experiences of the introduction of biosimilar versions of Remicade within the therapeutic area of
- Payer experiences of the introduction of a biosimilar within the therapeutic area of Cancer
What our experts say…
"Another key factor for us when considering reimbursement, is whether acceptance among the prescribers is very strong. Will the prescribers and their guidelines or key opinion leaders accept a therapeutic substitution? This is a challenge because you can't just therapeutically substitute a biosimilar; you need a new prescription, so the question is: are prescribers willing to work with us to do that?"
"The rebate trap has been on the mind of most PBMs and payers, but in the last 12 months things are beginning to change. PBMs are starting to realise that they have been focusing too much on keeping drugs with the biggest rebates on the formulary. As a result, they're starting to consider the total cost of a drug, prescription abandonment, and higher medication adherence and building those factors into their pharmacy programmes. For example, if there's a biosimilar that shows lower abandonment and higher medication adherence, PBMs take that into consideration."
"As long as the delivery device of the biosimilar is similar enough so that the patient doesn't have a negative event, there's KOL support for the biosimilar, and enough clinical evidence to support that product being AB rated, then we're not going to have a problem with switching from one biosimilar to another. However, you just can't send the alternative biosimilar to members; Pharma needs to be working with the payer and prescriber community to educate patients about the product. You just don't ship and pray. You ship and educate."
"Real world evidence will always be an effective method for proving the value of biosimilars. Payers are most concerned with safety, effectiveness, quality and cost. Substantial RWE directly drives a payer's confidence in choosing biosimilars to include in their formularies."
What to expect
- A detailed report revealing payer ambitions for the US biosimilars sector and the challenges it faces
- An examination of 12 key issues which originator and biosimilar drug developers need to understand and respond to
- 20 targeted questions put to experienced payers
- Their perceptive responses that provided 47 insights supported by 199 directly quoted comments
Expert payer contributors
This report harnesses the critical insights of experienced US payers. Their identities have been kept anonymous to ensure free and frank expression of views.
- Payer 1 has been the Chief Operating Officer and Executive Vice President PBM/Health Informatics at a leading Pharmacy Benefit Management company for over 18 years. He is responsible for overall pharmacy strategic initiatives, including clinical programmes, operations and trade relations with the pharmaceutical companies. Payer 1 has more than 24 years of experience in healthcare, working with the nation's largest insurers, health plans, pharmacies and pharmaceutical companies. His experience includes pharmacy operations, clinical operations, and formulary and rebate management and disease management programs.
- Payer 2 has been the Director of Managed Care Pharmacy for almost 7 years. He is a qualified Pharmacist, with over 39 years' experience within the pharmaceutical industry. He has held previous senior roles with companies such as MetraHealth and Aetna. He has expertise in pharmacy benefit analysis and strategy, new drug pricing and marketing, drug cost modelling and financial analysis. He currently supports pharmacy actuarial analysis and the drug and medicinal pipeline unit.
- Payer 3 has been the Chief Medical Officer at a provider-sponsored US health insurance company for the past 18 years, with responsibility for biosimilar formulary placement and contracting decisions. A Senior Physician Executive, Payer 3 has worked for over 20 years in managed care in Medicare and Medicaid. He is an expert in population health, pay for performance, provider profiling, medical cost control and analytics, network development, PBMs, product strategy and sales, and integrated systems.
- Payer 4 is the Vice President of Payer Sales at one of the fastest growing health care technology companies in the US. The company facilitates appropriate access to medication for patients by connecting the health care network, including pharmacies, providers, EHRs, plans and PBMs. He has over 12 years of experience in the health care industry, working with health technology companies and health insurance companies. His experience includes sales management, business development, client relationship management, defining market approach, product positioning and utilizing market intelligence in strategic development.
- Payer 5 is a qualified Pharmacist and currently holds the role of Senior Pharmacy Director at a leading managed healthcare company. He has nearly 7 years of experience working within the pharmaceutical industry for various payer institutes and is dedicated to balancing clinical and financial requirements to ensure that members receive optimum, yet affordable care. He also helps to shape strategies and policies which promote efficient access to medications for all members.
- Payer 6 is a Pharmacy Director with responsibilities for several large national and regional health insurance clients, as well as within the pharmacy benefit management industry. He is responsible for the development of clinical strategic initiatives and the creation of new benefit designs and programmes. He has extensive knowledge and experience with biosimilar formulary and coverage decisions and is involved with the committee that provides direction and establishes policies related to formulary development and management. In addition, he manages coverage programmes and establishes criteria to encourage drug therapy that is both appropriate and economical through the implementation of utilisation management programmes, including prior authorisation, quantity limit, and step-therapy programmes.
- Payer 7 is a US Benefits payer with 12 years' experience with state and local health agencies. He is responsible for government managed care benefit programmes operations, project management and process improvement. He provides direct operational support to an internal pharmacy department, which owns accountability for formulary development/updates, pharmacy encounters data management, PBM relationship management and drug cost trend savings initiatives and programmes.
- Payer 8 is Vice President of a non-profit healthcare company and integrated delivery network, with wide expertise in the fields of health, life, and disability insurance. He has nearly 30 years' experience, working for various leading healthcare companies, and is focused on achieving established business objectives and contributing to the continued success of organisations. He has carried out both consulting and non-consulting roles related to domestic and international insurance operations.
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