Adoption of Oncology Biosimilars into Clinical Practice - Episode 9

Challenges for Coverage of Biosimilars

April 29, 2021

Overcoming barriers for payer coverage of biosimilars as well as considerations for carrying costs are discussed.

Bhavesh Shah, RPh, BCOP:We talked about the electronic medical record. Ryan, you talked about pathways and how you guys control the prescribing of biosimilars. I’ve heard a lot of challenges with this, even in a list I saw recently. I saw a post regarding whether there is a software or some type of a platform that I can use to identify what biosimilar is covered by payers and what changes are being made on a regular basis in coverage. How do you guys manage this? Obviously, payers change their policies pretty frequently. Brandon, do you want to take this one?

Brandon Dyson, PharmD, BCOP, BCPS:Sure. It’s a moving target and an ongoing challenge. We’ll start with how NCCN [National Comprehensive Cancer Network] is our standard-of-care guidelines for clinical practice in oncology. Once the NCCN Guidelines have recommended using something like bevacizumab or another biosimilar, then you’re golden. But what happens when this particular payer wants a specific biosimilar vs another? Then it gets a little trickier, especially in an outpatient community setting. There are 5 FDA-approved Herceptin [trastuzumab] biosimilars. I can’t carry all those because the carrying cost would be astronomical, so we have to choose 1. We found a lot of flexibility actually if you ask. We saw this with the pegfilgrastim biosimilars: We have a preferred 1 and order for that, and then the payer might kick back and say, “No, we want this other 1 instead.” In layman’s terms we’re like, “Come on.” We’ve come back at them with that. It works most of the time. They want a biosimilar. If they really dig their heels in or draw a line in the sand, then we have to work with that and do the best we can with it. But we’ve had a pretty good success rate by pushing back just a little. That’s helped quite a bit.

Bhavesh Shah, RPh, BCOP:Ryan or Tim, have either of you experienced similar interactions with your payers in terms of being able to push back on them and being able to change their formulary so you don’t have to carry 10 biosimilars or have a reference product that you have to use more?

Ryan Haumschild, PharmD, MS, MBA: Yes, to an extent. We really try to review our major payers, and working close with our managed care team has been essential. To Brandon’s point, most are parity among biosimilars, at least if you’re doing that over originator. But we have seen some regional plans prefer the originator because some direct contract they have with them or with a direct biosimilar. We have a pathway for that. But when you can get the 80/20—with 80 as approval—that’s been really helpful. Then as negotiations roll out, we continue to push for parity among biosimilars. That’s really the success rate. If we have to change our contracting at an entity level, as long as it’s parity biosimilar, we can still remain agile, and we don’t walk ourselves into 1 biosimilar for the long haul. This is because we know ASPs [average sales prices] are always changing along with pass-through status. We know we’ve got to stay agile as much as our payers.

Bhavesh Shah, RPh, BCOP:You mentioned carrying multiple biosimilars and carrying the reference products. Is there some carrying cost that we should be talking about here too?

Ryan Haumschild, PharmD, MS, MBA: I absolutely think there is. To Brandon’s point, I have many infusion centers, and you can’t keep inventory of every single drug. This especially applies when there are 5 biosimilars for 1 medication product. If you extrapolate that across all 5, you’re going to be carrying a lot. There are carrying costs associated, but there’s also 340B Drug Pricing Program cost accumulation. As I accumulate toward each product, I’m also taking on that WAC [wholesale acquisition cost] onboarding expense. When you quantify that, it’s pretty expensive when you have more than 1 product. Carrying costs are a real thing, and they’re something that my CFO [chief financial officer] and I watch pretty closely.

Bhavesh Shah, RPh, BCOP:Thank you for sharing that. We forget that there’s actually this cost of adopting a biosimilar into your practice, right? There’s carrying cost. There’s all this infrastructure that you need to do provider education. You need to have your electronic medical record functional to support the different biosimilars that you may have to carry. Not to mention the coding, billing, and prior authorization—all the administrative things that need to happen. We forget that the more you have to carry, the more risk you have financially and for denials in case a wrong treatment is prescribed.

Transcript edited for clarity.