What We May Have Here Is a Failure to Communicate

Since the adalimumab biosimilars are typically covered under insurers’ and health plans’ pharmacy benefit, pharmacy benefit managers (PBMs) will be the key drivers of these upcoming coverage decisions.

Pharmacy benefit managers and their client health plans and self-funded employers do not necessarily have the same incentives. This is unfortunate, and may cause issues in the time leading up to the greatest biosimilar opportunity to date (and perhaps of our times). We have all heard that the sole key driver for a PBM’s biosimilar decision making is the net cost (and how this figure is arrived at, with rebates at the center of discussion). Although the health plans do want to minimize cost in their coverage decision making, they have other priorities as well. They are very concerned with patient care disruption and with provider relations.

If one corporation owns both the PBM and plan (e.g., CIGNA–Express Scripts or Evernorth), this alignment may be a bit closer. But it doesn’t have to be.

Let’s consider the following situation: The PBM makes the decision to cover only Humira in February 2023 to take advantage of the increased rebates. Their client health plan, on the other hand, wants to cover biosimilars instead, ready to move on from the reference product. Even at this late date, the plan hasn’t been informed of the PBM’s adalimumab policy. Does this sound surprising? This is actually the case for the payers we’ve spoken to—they are awaiting serious discussions with their PBMs about adalimumab contracting in 2023.

It may well be that the PBMs are undecided, awaiting an offer from AbbVie and the biosimilar makers. It may be that the PBMs are reluctant to make any long-term decisions on biosimilars until the second half of 2023. This makes sense, since the majority of launches will occur around the July timeframe.

The payers and large employers are not completely beholden to the PBM’s adalimumab strategy. Instead of accepting the latter’s standard formulary, they can opt for a custom formulary, where they have greater direct input on key product decision making. Our PBM contacts say that these custom formulary preferences may be more frequent now; the specter of savings from adalimumab may be driving it. Furthermore, if the plan is dissatisfied with their PBM’s embrace of biosimilar adalimumab, or their lack of communication around their plans, this trend may accelerate.

Without informative, frequent, and transparent PBM-plan communications regarding this critical drug category, payers’ expectations of savings may not be met. That can play into AbbVie’s hands; it is a lot easier to simply maintain the coverage status quo if AbbVie offers attractive savings than to embrace the competition and work to move marketshare.

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