The last of the big 3 PBMs, which control upwards of 80% of US pharmacy benefit spending, has yielded to the competition. OptumRx will exclude Humira from some of its drug formulary offerings as of January 1, 2025.
According to OptumRx, “Optum Rx will exclude Humira and prefer FDA-approved adalimumab biosimilars effective January 1, 2025 for patients new to therapy. Existing Humira patients will be able to continue therapy without switching to a biosimilar if they choose, with improved Humira pricing.” This grandfathering policy may end later in 2025, according to the release.
Amjevita® will be the primary biosimilar covered on its commercial formularies. The unbranded version of this biosimilar will also be offered as a private-label product through Nuvaila, a subsidiary of UnitedHealth Group. All other adalimumab biosimilars (and Humira) will be excluded on its Premium and Select formularies. On its Premium Value Formulary, the unbranded form of Cyltezo® will also be covered.
Currently, some biosimilars (e.g., Amjevita, Cyltezo, and Hyrimoz®) are covered at parity with Humira on OptumRx’s major national formularies, based on a search of Clarivate/DRG’s formulary reference.
On a related note, OptumRx also announced that Amgen’s ustekinumab biosimilar will be covered at parity in 2025 with Stelara®. This unbranded form of Wezlana® will be private-labeled and distributed by Nuvaila (both low-WAC and high-WAC versions).
Judging from CVS Health’s and Evernorth’s actions earlier in the year, no one is surprised that the shift to biosimilars has been strongest for products distributed by their own subsidiaries (Cordavis and Quallent, respectively). However, in the case of Evernorth, these are not necessarily the least expensive biosimilars on formulary. The discount on its Quallent-distributed private-label products amounts to only 46% below the wholesale acquisition cost of Humira. This pales in comparison with the > 80% discounts associated with other low-WAC biosimilars covered by its PBM Express Scripts. It sounds like a considerable financial incentive for the PBM, each time a prescription is filled with one of its private-labeled products. This sounds like a regulatory matter.
In Other Biosimilar News
A study published during the summer in the American Journal of Managed Care confirms what industry observers have suspected for some time: Self-funded employers often use employer benefit consultants to negotiate rebate guarantees from pharmacy benefit managers. According to the authors (with the National Pharmaceutical Council), over 60% of surveyed self-funded employers receive rebate guarantees on specialty drugs, and the employers often don’t know how much they are actually paying for these products. The implication is that the drug formulary includes higher-cost drugs and thus higher total pharmacy costs.
