Payer Preferences May Help Drive Biosimilar Uptake and Sizeable Savings in Oncology

A poster presentation highlighted the impact that payer preferences could have on biosimilar utilization and the potential savings that could be generated if payers decide to take advantage.

Oncology biosimilars are getting a bigger chunk of the pie under health plans that equip utilization management strategies that do not prioritize reference products over biosimilars, according to a poster presented at Academy of Managed Care Pharmacy 2021.

This study showed that commercial and Medicare plans could successfully improve uptake of biosimilars and generate savings by implementing step therapy requirements that favor biosimilars or refraining from prioritizing either a biosimilar or reference product.

In 2020, the total cost of cancer care was estimated to be $207 billion, marking a 66% increase since 2010. Additionally, the use of biologic drugs used for cancer treatments has expanded rapidly.

Blockbuster reference biologics Avastin (bevacizumab), Herceptin (trastuzumab), and Rituxan (rituximab) accounted for the highest drug spend from 2011 to 2016, totaling $8.6 billion in the United States. As of 2019, 9 biosimilar versions of these drugs have been launched on the US market: 2 bevacizumab biosimilars (Mvasi and Zirabev), 5 trastuzumab biosimilars (Kanjinti, Ogivri, Ontruzant, Herzuma, and Trazimera), and 2 rituximab biosimilars (Truxima and Ruxience).

Currently there are no biosimilars that have an interchangeability designation, which would allow for patients to receive a lower-cost biosimilar instead of a more expensive reference product more easily. Without the flexibility of interchangeability, payer policy decisions become a potential avenue to drive biosimilar uptake and subsequent savings.

The retrospective, cross-sectional analysis was conducted between June 6, 2019, and June 6, 2020, and included prior authorization and administrative medical claims data sourced from Magellan Rx Management’s and Medicare databases.

Formulary decisions by health plans were categorized into 3 groups based on their biosimilar coverage policies:

  • Biosimilar preferred: step therapy approach where patients are given the biosimilar before having access to a reference product
  • On par: neither the biosimilar nor the reference product are listed as a preferred product
  • Nonpreferred: step therapy approach where patients are given the reference product before having access to a biosimilar

Of 252 medical formulary decisions across 16 commercial and 12 Medicare Advantage plans, 30% had biosimilar preferred coverage, 4% had nonpreferred coverage, and 66% had on par coverage.

Across the databases, 7591 prior authorization approvals were included in the analysis: 5374 for reference products and 2217 for biosimilars. Since oncology biosimilars launched on the market in the third quarter of 2019, uptake has grown steadily, even surpassing the utilization of the reference products during the first quarter of 2020.

Despite no interchangeability designations, 410 (8%) of the approvals for the reference product were independently switched to a biosimilar midcourse of their therapy. In addition, switches occurred more often in physician practices (68%) than outpatient hospital departments (32%).

“Data also indicate that some providers are proactively switching patients to oncology biosimilars even without biosimilar preferred coverage,” wrote the investigators.

They estimated that Medicare and commercial plans could generate over $67.2 million in savings over 1 year by steering 50% of patients toward oncology biosimilars.

Additionally, by pivoting to a more biosimilar-friendly coverage program, plans could save an estimated $35.6 million, $11.6 million, and $19.9 million on total claims for bevacizumab, trastuzumab, and rituximab products, respectively.

A limitation of the study was that prior authorization decisions may not fully reflect biosimilar utilization, because patients may have received alternate treatments, never received a biosimilar, or received the reference product through manufacturer assistance programs. The true savings were also difficult to determine because different payers have different rebate arrangements.

“Longer follow-up and corresponding claims analysis may provide further insights on the true uptake in biosimilar use and cost savings being achieved,” the investigators noted.


Fowler A, Borgert R, Polson M, Lawson K, Rebello J, Makanji H. The emergence of therapeutic oncology biosimilars: Payer’s perspective. Presented at: Academy of Managed Care Pharmacy 2021; April 12-16, 2021. Poster C19. Accessed May 13, 2021.

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