A study by IQVIA on adalimumab biosimilar savings found billions of dollars in lost opportunities in 2023, primarily because of pharmacy benefit managers’ (PBMs’) incentives to block biosimilar use.
AbbVie’s financial statements indicate that Humira® net US sales revenues were more than $6 billion lower in 2023 compared with 2022. IQVIA’s study asserts that an additional $5.7 billion may have been saved over the first 11 months of 2023 if all Humira use was converted to biosimilar prescriptions. However, this would have driven PBM profits down by nearly 90% in the drug category, based on lower rebates, lower fees to their specialty pharmacies, and lower drug reimbursements overall. Clearly, the PBM industry has an incentive to protect $2 billion in related profits.
According to the analysis, released on April 2, “Humira remains a costlier option than biosimilars for health plans even after rebates, with a net price of about $2,100 compared to less than $1K for some biosimilars.” This assumed a biosimilar low wholesale acquisition cost (WAC) of $1,007, a Humira WAC of $6,922, and a Humira net price of $2,129. In that case, the low-WAC biosimilar net price would be about $775.
On a more granular level, IQVIA estimated that only one-third of members of large health plans given a prescription for an adalimumab biosimilar would have been able to fill it within 30 days. Thirty percent would have faced NDC blocks, and 14% would have been rejected for failing prior authorization criteria. Other rejections may account for 14% of failed dispensing, and abandoned prescriptions may account for another 10%.
Smaller payers have been responsible for the majority of adalimumab biosimilar uptake in 2023 (only 1%), because they “stand more to gain from low-cost, no-rebate formulations.”
The study was sponsored by the Biosimilars Council. In a press release, Craig Burton, the Council’s Executive Director, said, “Rebate and fee revenue tied to the list price continues to maintain a stranglehold on coverage decisions, to the detriment of patients and ultimately payers.” He added that “even when plans cover the biosimilars, they place the biosimilar on parity with the higher-priced brand and remove any incentive for patients to use the lower-cost biosimilar. It is critical that Congress enact legislation to rein in such PBM abuses.”
Based on these figures, self-insured employers (as plan sponsors and employing plans and PBMs in administrative-only services) will be best advised to closely examine their adalimumab savings opportunities. In addition, health plans should analyze what their true net costs are in this category—even with large rebates, the low-WAC biosimilar options may yield significantly lower net costs than provided by Humira’s manufacturer.
As we indicated in an earlier post, this PBM-related issue will likely be raised once again with the launch of the next high-profile biosimilar covered under the pharmacy benefit— ustekinumab (Stelara®) in 2025. The sooner payers and PBMs change their strategies from emphasizing rebates to embracing value, the better the chance we’ll obtain optimal savings in the immunologic drug category.
