Are PBMs Covering Biosimilars?(Part 5 of 5)

After the market entry of the first biosimilar, Zarxio, in 2015, PBMs have deployed a myriad of coverage strategies for biosimilars. Currently there are 18 biosimilars available in the market, of which nine are indicated for oncology, six for hematology, and two are for inflammatory or immunologic conditions.

Therapeutic Categories of Biosimilars Available on the Market

Over the years, coverage policies applied by PBMs have varied dramatically from plan to plan, sometimes even within the same PBM.  In this blog, we evaluate if the top five PBMs by market share are converging biosimilars as of April 2021 on their publicly available formularies.   

Number of Top Five* PBMs that Have Each Biosimilar on Formulary

Top Five PBMs determined by market share. Three Tier 1 PBMs have at least 20% market share. One Tier 2 PBMs have 4-10% market share. One Tier 3 PBMs have less than 4% market share.

Except for few products that were covered by all PBMs evaluated, our review of publicly available formularies show that coverage of biosimilars varies widely from PBM to PBM. 

This variation in formulary placement of available biosimilars should be concerning to plan sponsors and patients.The successful uptake of biosimilars and the realization of their savings potential is directly tied to how PBMs choose to place biosimilars on their formularies.Thus, it is critical for plan sponsors to take a proactive role to engage in conversations with their PBMs regarding biosimilar coverage policy.