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As debate rages over adoption of biosimilars in the U.S., a new analysis finds that 17 of the largest commercial health plans last year rarely preferred these versions of brand-name biologics when crafting coverage decisions.

Specifically, the insurers made 535 coverage decisions last year for nine biosimilars that were available in the U.S. But the health plans required patients first try a biosimilar before gaining access to a brand-name biologic just 14% of the time. By contrast, brand-name medicines were favored in 33% of the coverage decisions, while preferred coverage was offered for both medicines 53% of the time.


Looked at another way, 10 of the 17 health plans chose not to offer preferred coverage for biosimilars at all, and only two health plans made biosimilars a preferred choice half of the time or more. Although coverage differed among health plans, the findings illustrate the difficulties biosimilar makers have encountered, broadly speaking, in gaining access to insurance coverage.

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  • one issue is that biosimilar developers and marketers came into this expecting they could still rake in lots of $$ without major discounts. that’s understandable given they need to spend the time and money to do large clinical trials (unlike traditional generics). they thought they could take the market with just a 15-20% discount over the brand price, but J&J (for example) isn’t about to give up a billions of dollars without a fight. They just rebate to match these relatively minor discounts. Doctors and patients aren’t comfortable switching patients already on the brand (which brands spent years and lots of $$ ensuring), which gives the brand companies more leverage. The answer is price. Will J&J match a 50% discount? How about 60%? I heard that Norway or another Scandinavian country negotiated a 70+% discount for a biosimilar back in 2006 or so. But that’s not the business model biosimilars built there products around…

  • uhhh, you do realize that biologics are large molecule and all are injectables, not orals, right? The choice of art to accompany the article paints Stat in a poor light.

  • May I observe that I recognize this estimate – “they could have saved an average of $1.5 million and their employees would also have spent hundreds of dollars less.” It has been used here before, but some a savings of $1.5 million / year doesn’t sound like a great deal – to the working / even middle class, definitely, but in the corporate framework?

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