From our experience with the adalimumab biosimilar launches in 2023, we learned several lessons. One is that our existing pharmacy benefit manager (PBM)–driven rebate system dictates not only coverage but utilization. Second is that employers must flex their leverage muscle if they want full pass-through of rebates and full transparency regarding PBM-based rebates and fees. Third, reference product utilization will not decrease unless they are excluded from the formulary or at least disadvantaged—simply, coverage of biosimilar agents does not necessarily mean more biosimilar agents being dispensed.
The National Alliance of Healthcare Purchaser Coalitions has released a new survey of employers, which has several implications for the biosimilar industry. For instance, one finding is employers are beginning to move towards more transparent PBM strategies. This could or should favor biosimilar utilization, as employers slowly shift to less focus on rebates and more focus on fiduciary responsibilities to their employees.
The survey was conducted this summer and was responded to by 324 employers and purchasers across the nation. Nearly half of the employees surveyed were between 1,000 and 9,999 workers in size, with 17% being smaller than 500 employees. Two thirds were privately owned business. Forty-nine percent were self-insured, 17% were fully insured, and the remainder were a combination of the two.
The National Alliance found that concerns over the cost of drugs, hospital care, and high-cost claims for treatment (cell and gene therapies) are pervasive. The focus on high-cost claims management was apparent through the greater adoption of patient screening, third-party disease specific vendors, and stop-loss insurance policies.
Ninety percent of the respondents worried that the annual rising cost of healthcare has reduced their organization’s competitiveness, and 92% expect that additional healthcare cost-shifting to employees will be the result. Higher copays and deductibles should persuade consumers to lean toward biosimilars’ lower cost at the point of dispensing.
Importantly, employers’ reliance on big three PBMs dropped from 72% in 2024 to 61% in 2025, according to the survey respondents. The demand for transparent PBMs increased from 12% in 2024 to 31% in 2025. Sixty-one percent of the purchasers responding indicate that they have either changed to a transparent PBM in the past year (6%) or are considering a change within 3 years (55%). Eighty-six percent characterized drug prices as a significant threat to healthcare affordability. Forty-five percent believe PBM conflicts of interest are a significant threat to affordability (41% believe this represents a “minor” threat). In its report, the National Alliance stated, “Employers that report complete claims access are consistently more likely to be engaging in hands-on strategies across PBM contracting.”
The more hands-on corporate employers become with their pharmacy data, the better for the biosimilar industry. Third-party benefits consultants are also subject to conflicts of interest with PBMs. The annual cost trend seems to support this: A greater proportion of respondents using a transparent PBM saw lower or stable premiums this year (71%) compared with those using the CVS Caremark, OptumRx, or Express Scripts (59%) and were 55% more likely to see lower premiums (42% vs. 27%, respectively). Sixty-two percent are requiring full and independent audits of PBM contracts and rebate agreements.
According to the National Alliance, 65% of employer respondents are actively promoting and utilizing biosimilars on formulary. Remember, simply providing access to a biosimilar is not the same as excluding the reference product or promoting a biosimilar to preferred, with a lower copay or coinsurance.
Overall, this new report shows movement in the direction that the National Alliance has tracked in the past, that better value is to be found with biosimilars and employers are becoming more aware of it.
