Management of specialty drugs, specialty pharmacies and biosimilars in the United States

Background: Specialty medicines continue to increase as a percentage of spending with biologics representing a large portion of specialty spending. Health plans expect to adjust their formularies to maximize expected savings from biosimilars. Objectives: A better understanding of health plan management of specialty pharmacy (SP), SP products and biosimilars. Methods: Online survey of health plan executives on: roles and plan information, specialty pharmacies and specialty pharmaceuticals, expected biosimilar coverage/restrictions/copays. Results were compared with prior surveys (changes >2% reported). Results: Survey completed by 85 respondents: 42.9% were senior officers, 13.1% regional, 8.3% payor specific, 1.2% therapeutic area specific; 36.9% worked for healthplans, 13.1% PBMs, 9.5% IDNs, 2.4% PPOs/IPAs, 1.2% Government. Plans were national = 29.9%, regional = 24.7% or local = 22.1% and cover multiple member types: commercial (58.6% = FFS, 77.8% = HMO/PPO), Medicaid (Traditional = 27.8%, HMO/PPO = 72.3%), Medicare (71%, PDP-only = 51%), Employer/Self-funded = 79% and IDN (43.6%, 340B Qualified = 43.8%); 45.6% reported the plan’s PBM as their SP provider and providers were restricted by 58% ↓23% with plans restricting products: 58% to those under contract, 11.6% for those available through multiple SPs, 10.1% allow any SP handling a product and 4.4% carving out their SPs. Compared with last year, providers shifted approximately 6% from independents to internally provided and currently 45.6% are PBM owned, 38.2% health plan owned, 25% independent and 13.2% hospital/IDN owned. SP products continue to move from fixed to percentage copays with more plans determining by group and benefit design. Plans covered clinician-administered products under the medical benefit (36.8%↓7.3%), 2.9% under the pharmacy benefit; the remainder used price and plan design. Biosimilar use expected for all reference product indications 58.8%↓5.7%, 31.4%↓13.5% will restrict to approved indications and 9.8% will use indication as the basis for copay. 10%↓15% expect the biosimilar to be the only product available, copays are expected to be discounted off the innovator 58%↓10.1% and 32%↓4.9% to vary based on approval timing. Biosimilar education provided through: different copays = 64.7%, prescriber and patient mailings (76.5%↓4.2% + 58.8%), prescriber and patient calls (51%↓10.6% + 27.5%↑4.1%). Biosimilar savings are expected to be 63.5% this year; in 5 years, 66% of savings are expected to be greater than 20%. Conclusions: Costs associated with specialty pharmacies and specialty pharmacy products have shifted and are expected to grow with some relief coming from biosimilars.