Pharmacy benefit managers (PBMs) will play a large role in determining which adalimumab biosimilars are dispensed. These companies function as intermediaries between insurance companies and biotech manufacturers, negotiating contracts and settling on a purchase price. This price is further influenced by rebates the manufacturer grants to the PBM according to sales volume.
“It’s conceivable that AbbVie may decide to remain highly competitive and carve out better deals with PBMs to maintain its market share,” says Dr. Helfgott. “If that’s the case, for a lot of plans, nothing will change.”
It is to the advantage of PBMs to have higher list price medications on their formularies, notes Dr. Snow, because their reimbursement is partly based on the list value.
“I think a lot of people’s concerns are that the objectives and goals of the PBMs are not always aligned with the objectives and goals of the patient or the prescriber,” says Dr. Helfgott. “We’re going to have new products on the market, and what the prescriber may think is the appropriate thing to do may not be what the PBM has in mind at all.”
The ACR supports the use of biosimilars in biologic-naive patients for whom the product is the best option, notes Dr. Snow, citing the ACR’s position statement on the topic. However, the statement also makes it clear that patients on a biologic without a biosimilar available should not be switched to a biosimilar of another class without medical reason. The ACR advocates that the decision to switch from a reference biologic to a biosimilar lie with the clinician and the patient.2
“Insurance-mandated switching takes the decision out of the hands of the rheumatologist and the patient,” says Dr. Snow. “It can be frustrating because when you find something that works for a patient who has had tenuous control of their disease, the last thing you want to do is to change what has been working. It is especially frustrating when this is due to a contractual change at the insurance level and not a change based on what the patient needs at that moment.”
“I do not think that the insurance companies or the PBMs will care whether the patients have previously been on a biologic or not,” says Dr. Helfgott. “We’ve seen this behavior many times before, where payers make mandates and [force changes on] patients who are doing well on their current drugs.”
