Optimizing the Transition to Biosimilars: Considerations for Payers - Episode 8

Evaluating Biosimilar Programs and Formularies

Kathy Oubre, MS, closes this Insights program by evaluating her organization’s biosimilars program and formularies, including third party preference on the use of specific biosimilars and whether biosimilars can be used outside of their indications.

Kathy Oubre, MS: We evaluate new approvals and possible switches to our internal formulary a few weeks before the start of a quarter. The stakeholders involve all of the HCPs [health care providers] and the business office, including someone from the financial team, the authorization team, as well as myself.

The information around the biosimilar pipeline does come from a lot of reading and a great partnership with our GPO [group purchasing organization]. It’s in conversations with our pharmaceutical partners, those biosimilar pharmaceutical partners and educating us around their offerings and what they do have coming down the pipeline. This can be really fun when you have particular patients who do have potential financial insecurities around particular products and being able to afford the therapies and knowing that pretty soon you might have some answers for them and ways to help increase their access to care and alleviate their financial burden. At the end of the day, that’s why we all get out of bed in the morning, to provide the best care possible for our patients. Anything that we can do as health care providers, from the science around it, and also helping to relieve that financial burden, those are 2 huge wins in patient care.

In an ideal world, our organization would have 1 drug per indication on our formulary. However, these decisions are really more dictated by the payers and their formularies. We stock 2 to 3 products per reference product. How do we distinguish which biosimilar products we prefer in our organization? That’s not an easy answer. As an organization, determining which and where each product sits on our practice formulary is a marriage between the payer formulary, the drug acquisition cost, and payer reimbursement.

Our providers have been eagerly watching the biosimilar space and the market for a few years prior to the launch of any biosimilar in the oncology space. They’re pretty familiar and comfortable around the science, the approval process, and the way they all became available. We do continue to watch the idea of interchangeability, which will be a huge win in the oncology space when we achieve interchangeable status, but until then it hasn’t been a large concern within our organization. If and when it is, on the provider and even the patient perspective, or from a nursing perspective, we have developed educational tools for all of those segments of our population, and we continue to update them as new science and new findings come into the market.

Payers and PBMs [pharmacy benefit managers] have the most significant impact on our biosimilar choices at Pontchartrain [Cancer Center]. PBMs and private payers vary in their approach to biosimilars. Although some PBMs and payers include biosimilars on their formularies without real aggressive management, some will only approve the originator product. Others will create preferred coverage for 1 or more biosimilars. The rub becomes when different payers approve different biosimilars on their formularies.

As an organization, years ago we made the decision to not do any type of off-label medicine. One of the ways that we ensure that is the treatment plans are not built within the EMR [electronic medical record] if they’re not within that labeled indication. If a provider goes to look for that particular treatment plan for an off-label indication around the biosimilars, they won’t find it. There are some hard stops within workflows in our organization so that if something were to be developed and go to the nursing team or the authorization team, and it’s for an off-label indication, it does flag with those people because they do keep some flag material, some hand-written lists to the right of their desk that talk about biosimilars by payer and indication. They will then go back to that prescribing provider and educate them to pick an approved biosimilar or a different product.

This transcript has been edited for clarity.