Biosimilars: US Payer Insights 2020

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Publication Date:
April 2020
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What do payers see as unlocking the sluggish US biosimilar market?

Despite the availability of biosimilar versions of Avastin, Herceptin and Rituxan, payers are not pleased with the development within this sector. Insufficient discounts on biosimilar drugs and aggressive contracting strategies by originator companies together weaken the appeal of biosimilars. Payers also cite obstacles such as an inability to extrapolate biosimilar use across all indications of the reference product. With biosimilar Humira and Enbrel on the horizon the potential for significant savings is recognized, so what insights do payers have for biosimilar manufacturers wanting to make a breakthrough?

Understanding the issues that are shaping US payer behaviour is critical. That is why we have interviewed in-depth 8 experienced US payers to reveal in Biosimilars: US Payer Insights 2020 their attitudes, needs and the practical steps pharma companies can take to address their concerns.

Payers explore key questions such as...

  • What must pharma do to improve the way they engage with patients, physicians and payers?
  • 40%? 60%? What discount levels would really capture payers' attention?
  • What lessons can the US learn from Europe's success with biosimilars?
  • Will interchangeability guidelines help companies demonstrate biosimilar efficacy and safety and what impact will interchangeable biosimilars have on adoption rates in the US?
  • What strategies are encouraging physicians and patients to switch to biosimilars and how are these likely to evolve in the future?
  • Are regulators doing enough to discourage the unfair contracting practices carried out by developers of innovator biologics?
  • How will biosimilar Humira and Enbrel change the landscape for biosimilars in the US and why?

What payers say...

"If companies were making efforts to understand our goals, I think that biosimilars would have come to the market with a higher discount than they have so far. I think that biosimilar manufacturers really need to better understand how the reference manufacturers are responding to biosimilars. Also, the limitations that limit our ability to force a step through of a biosimilar because of the different indications. It also limits our ability to put biosimilars in a similar place to the reference products. So, I think that they need to understand how we can best use biosimilars and achieve our cost savings."
Medical Director
Mid-sized national payer

"I think the institutions, compared to the health plans, are having a much easier time converting to a biosimilar. The health plan may have contracts with a branded originator that may impede the need to go to a biosimilar. And what do you do with existing patients? So, it's perhaps easier to get new starts on a biosimilar. But two-thirds of your patients are stable and already on the branded product. We can try to create incentives to switch, at the patient's side or the provider's side. But that may be a very slow process, until we have interchangeability for the biosimilars. So, in the end we may actually do better by sticking with a branded originator, especially if there exists some discounting."
Chief Medical Officer
Managed care

"As a payer, if I am preferring adalimumab X, Y, Z instead of Humira and the pharmacy gets a prescription for Humira, they cannot automatically substitute the adalimumab that I prefer. Technically they have to pick up the phone, call the doctor and say, 'Humira is not covered for this patient, can we change it to adalimumab X, Y, Z?'"
Pharmacy Director
Large PBM

What to expect

A detailed report exploring US payer insights on the obstacles facing the US biosimilars sector and the key developments which could drive wider adoption and use through:

  • An examination of 15 key issues that impact the plans and prospects of biosimilar and originator companies
  • 34 targeted questions put to US payers
  • Their responses which provided 38 insights supported by 246 directly quoted comments

Expert contributors

Experts contributing to this report have been screened to ensure they have:

  • Five to 30 years' experience working in managed care organizations, pharmacy benefit management, or a State Medicaid Office
  • Been personally involved with developing policy that seeks to provide guidance on drug restrictions, step approaches, algorithms, etc
  • Direct experience of making formulary decisions for biological therapies in at least two of the following areas: oncology, rheumatology, gastroenterology, dermatology, endocrinology, neurology, nephrology or fertility
  • Direct experience of assessing biosimilars for inclusion on formulary, either as part of a committee or as the lead decision-maker


To ensure full and frank disclosure of opinion from experts, contributions have been anonymized.

  • Payer 1 is a Chief Medical Officer at a managed care organization with over 20 years of experience
  • Payer 2 is a Medical Director at a health insurance company that covers over 13 million lives
  • Payer 3 is a Pharmacy Director at a mid-sized insurance company with over 20 years of experience
  • Payer 4 is a Vice-President of Pharmaceutical Strategy and Contracting at a leading Pharmacy Benefit Manager with over 18 years of experience
  • Payer 5 is a Pharmacy Director at a large Pharmacy Benefit Manager covering 87 million lives
  • Payer 6 is a Clinical Manager at a national Pharmacy Benefit Manager with over 23 years of experience
  • Payer 7 is a Medical Director with 25 years of experience at a managed care organization and responsible for patient management activities
  • Payer 8 is a Pharmacy Director with over 16 years of experience at a national insurance company covering 40 million lives

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