Steal this idea: How this health plan got buy-in on biosimilars

Around four in 10 Health Alliance members taking adalimumab are prescribed biosimilar versions, and the plan is taking the leap to remove brand-name versions of the high-cost drug from its formulary.

Humira, used to treat rheumatoid arthritis and other conditions, can cost upward of $6,000 a month, and is the highest-grossing drug of all time. Biosimilar versions can cost significantly less. 

Biosimilar versions of adalimumab were introduced in January of 2023, and approaches to the drug from insurers and pharmaceutical benefit managers have varied. In April, CVS Caremark removed brand-name Humira from its formulary. Optum, another large PBM, covers biosimilars and brand-name Humira on the same tier in its formulary. 

Champaign, Ill.-based Health Alliance plan has 250,000 members in Illinois, Iowa, Indiana, Ohio and Washington. Leaders at the plan sat down with Becker's to discuss how they developed their biosimilar strategy. 

1. Provider buy-in: The transition began by reaching out to providers to advocate for biosimilar options, Brian Smolich, PharmD, vice president of pharmacy, medical utilization management and systems at Health Alliance said.

Health Alliance is owned by Urbana,Ill-based Carle Health, so the conversations started there, Dr. Smolich said. 

"Not every provider system allowed us access to have those conversations as willingly as our own vertically integrated health systems," he said. 

Health Alliance initially covered both brand-name Humira and biosimilar options. 

"I think for this initiative to be successful, collaboration with provider partners was necessary, versus a more hardline approach, saying we're not going to cover those therapies right out of the gate," Dr. Smolich said. "Being in an adversarial position with providers and patients being caught in the middle, we didn't want to see that." 

Michael Smith, MD, chief medical officer of Health Alliance, said there was a gap in awareness and understanding around biosimilar products. 

"Education was a very large part of the strategy that we took, explaining to physicians and advanced practice providers, why it is a completely rational step in trying to control medical costs while still giving their patients very sound therapy," he said. 

2. Transition: Currently, around 43% of adalimumab prescriptions for Health Alliance members are biosimilars, Dr. Smolich said. This number is higher among Carle Health patients, at 70%. 

Health Alliance plan will drop brand-name Humira from its formulary on July 1, Dr. Smolich said. 

"We've seen patients stable on these therapies for a year-plus now, and it gives us more confidence that the timing is right," Dr. Smolich said. "Providers have a comfort level in prescribing these." 

Dropping Humira from Health Alliance plan's formulary is the "lowest-hanging fruit" in terms of saving costs, Dr. Smith said. 

"We as an industry are going to have to make some difficult decisions about areas where we prioritize and areas where we save money," Dr. Smith said. "This should not be a difficult decision."

3. Future outlook: After taking a slower transition with Humira, Health Alliance may take a more hardline approach with future biosimilars, Dr. Smolich said. 

"The science is there, we're just asking providers to consider the same or a similar molecule made by a different company," he said. "They should have the same effectiveness, safety and rigor." 

The approach Health Alliance plan is taking with biologics may not necessarily work for other high cost drugs, like gene therapies or GLP-1s, Dr. Smolich said. 

"I don't know if our approach with biosimilars necessarily mirrors our approach in some of those other areas," he said. "But I think we're using what we've done in biosimilars to help provide dollars that will be afforded for those other therapies that we may have to cover in those spaces." 

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