Biosimilar Series: Part 4

In this episode, the fourth of our biosimilar education series, Neil Udovich spoke with Kathy Oubre, CEO of Pontchartrain Cancer Center, about the role of the payer in relation to biosimilars, the formulary management process and the differences in treatment of biosimilars by Medicaid and Medicare.

If you have any questions for our guests or have a topic you would like to learn more about, email us at OnCall@cencora.com. 

Transcript

[00:00:34] Neil: All right. Hi, Kathy. So we talked a lot about biosimilars and, and their efficacy within the patients and, and also a little bit about how a practice might consider their utilization, but I would imagine that a big factor in determining whether or not a biosimilar can actually be used is payer coverage. And so what is the role of the payer in the utilization of biosimilars?

[00:01:02] Kathy: Well, we typically see the, you know, the payers took a very active role in biosimilars and not everyone, but it was really interesting from a community oncology perspective that we had really not seen payers take an interest in formulary management until the biosimilars became available.

And we saw that, you know, kind of out of the gate in the Pegfilgrastim space and you saw payers have preferred products. So then we ha started dealing with issues of, you know, preferred, non-preferred. And then of course, some payers took the role of allowing them to have parity, you know, Medicare of course being, you know, the biggest payer that allows for parity, but you know, what should be the role of the payer?

You know, it should be to provide access to lower cost, high quality medications, with the goal of increasing access, to care for their beneficiaries. You know, however, over the last, you know, many years or we've seen payers and PBMs pharmacy benefit managers put a greater emphasis on cost minimization when outcomes are equal.

So, you know, it, it has trickled down to the practices to the physician level. And you know, when you have multiple products within a space, you know, Pegfilgrastim or any of the mav spaces. The larger payers, the larger commercial payers have engaged in formulary management. So, you know, for example, in the peg space, we have seven Pegfilgrastim currently on the market.

Now that is a lot of different products to manage for one space. You know, I do understand that, but what we've seen is these payers now approach pharmaceutical manufacturers  and, you know, ask for rebates that would go back to the, you know, the payer in order to have access to that particular payer's formulary.

So to be included on the formulary, you know, a pharmaceutical manufacturer might offer the payer, you know, a rebate incentive in order to be included on that formula and then from a, you know, a practice perspective, then we have to do that due diligence. And we'll talk about that later, when we discuss operationally operationalizing these things into our organizations, but we do have to be very diligent on ensuring that we are getting the authorized product.

So the one that the payer will prefer authorized for those particular patients and ensuring that that is then at the, you know, the point of administration that is the particular product that we are giving to the patient.

[00:04:16] Neil: And how often do those formularies change if you I'm an insurance company or a patient with the same insurance? That formulary change quarterly. Monthly?

[00:04:28] Kathy:  We have seen it change quarterly, not with a lot of, not with a lot of the man, you know, the payers, but we do see it change every now and then. And yes, they can move it to a quarterly basis. Most of them move maybe once a year, maybe twice a year, but some of your more nimble payers will move things on a quarterly basis, which is very challenging from an authorization standpoint.

Now to date, most that would essentially be new treats. You, you know, most of the payers don't wanna get into the middle of changing drugs on a cancer care patient or patients that are already in treatment and are, you know, responding to said treatment. So usually, you know, if a patient is doing well on a particular product that was authorized in the, you know, originally they will grandfather those and then, you know, any new payer updates would be considered appropriate or apply to new treat.

[00:05:38] Neil: And generally speaking, when a payer is managing a formulary and has certain drugs in a certain class un-preferred status. How many might you see in preferred status? 1, 2, 3?

[00:05:55] Kathy: Certain payers, you know, usually have one to three of a particular biosimilar, um, as preferred status. I was actually reviewing that a couple of days ago and yes, you'll see, I see two being the most common and, but almost no one, you know, other than Medicare, you know, including, you know, and to note, most state Medicaids have engaged in formulary management as well with, you know, Medicare really being the largest payer that allows for parity.

[00:06:34] Neil: So Medicare, you can use whatever biosimilar you want. There's no formulary management, but what about Medicare advantage plans? 

[00:06:45] Kathy: I have seen that most Medicare advantage plans have engaged in formulary management as well.

[00:06:50] Neil: What percentage of your Medicare population has an advantage plan?

[00:06:55] Kathy: About a quarter?

[00:06:57] Neil:  So certainly regardless of the payer or circumstance, there's always the need to do benefits, verification to ensure that the biosimilar that you want to use is able to be used in that patient at that time.

[00:7:13] Kathy: Yeah. So from an operational perspective, it's always very important to, you know, you need to authorize the correct product for the correct patient and then also at the administration level, when the pharmacist or the nurse, or whoever that is within the practice, you know, goes to pull out, you know, that particular product from the nucleus or whatever inventory cabinet they may have, you know, it's  important to put some stop gaps in place, to ensure that not only are you authorizing it, but also administering the approved product to the correct patient, because, you know,  if you don't do that, if you administer the unauthorized biosimilar to the patient, you run a very high likelihood of not getting reimbursed.

And these are expensive product. So, you know, a practice can only really afford to perhaps do that one or two times, and then, you know, you're gonna have a, you know, a financial issue on your hands for the practice.

[00:08:25] Neil: Well, great. Well, thank you for your insights as always Kathy.

[00:08:29] Kathy: Yep. Happy to help.