Patient Access To Cheaper Biosimilar Drugs Varies Significantly Across Pharmacy Benefit Managers

Forbes - Mar 5th, 2025

Patients using autoimmune treatments like Humira are seeing potential cost relief as biosimilar versions enter the market. However, access and savings depend heavily on pharmacy benefit managers (PBMs), who control drug coverage for millions of Americans. These PBMs, including major players like CVS Caremark, Optum Rx, and Express Scripts, often favor high-priced drugs due to rebate incentives. This has led to scrutiny from Congress and the FTC, who are concerned about anti-competitive practices and barriers to cheaper biosimilars.

The story highlights the complex dynamics between PBMs, drug manufacturers, and biosimilar adoption. While some PBMs like MedImpact are expanding access to more affordable biosimilars, others maintain practices that prioritize higher rebates over lower costs. Non-traditional PBMs such as SmithRx and CapitalRx are gaining attention for their models that favor the cheapest products, potentially reshaping the market. As the landscape evolves, these developments could impact drug affordability and access, prompting legislative and market shifts in the pharmaceutical industry.

Congress Pharmacy Benefit Managers Federal Trade Commission Humira Biosimilars Drug Pricing Health Policy Med Impact Optum Rx

Story submitted by Fairstory

RATING

6.8

Fair Story

Consider it well-founded

The article provides a comprehensive overview of the role of pharmacy benefit managers (PBMs) in influencing access to biosimilar drugs, highlighting the economic and regulatory factors at play. It accurately describes the complex rebate structures and market dynamics that affect drug pricing, making it a valuable resource for understanding these issues. However, the story could benefit from greater transparency in sourcing and more diverse perspectives, such as input from PBMs or patient advocacy groups. While the language and structure are generally clear, the inclusion of technical terms without sufficient explanation could hinder understanding for some readers. Overall, the article is timely and relevant, addressing significant public interest issues and contributing to ongoing discussions about healthcare reform and drug pricing transparency.

Accuracy

The story is largely accurate in its depiction of the role of pharmacy benefit managers (PBMs) and their influence on biosimilar drug access. It correctly describes biosimilars as having no clinically meaningful differences from their reference biologics, aligning with FDA definitions. The claim about the FDA approving 61 biosimilars by October 2024 needs verification, but it reflects the general trend of increasing biosimilar approvals. The article accurately portrays the complex rebate structures that influence PBM preferences for higher-priced drugs, a well-documented issue in pharmaceutical economics. However, the specific details about PBM practices and their formulary decisions, such as the exclusion of certain biosimilars, should be cross-verified with PBM announcements or industry reports to ensure precision.

Balance

The article presents a balanced view by discussing both traditional and non-traditional PBM models. It highlights the criticisms faced by major PBMs while also noting the efforts of companies like MedImpact and SmithRx to offer cost-effective alternatives. However, the story could benefit from more perspectives, such as input from PBMs themselves or patient advocacy groups, to provide a fuller picture of the issue. The focus is primarily on the economic and regulatory aspects, with less emphasis on patient experiences or healthcare provider insights, which are crucial for a comprehensive understanding.

Clarity

The article is well-structured and clearly explains complex topics like PBM practices, biosimilar drugs, and rebate systems. It uses straightforward language and logical flow to guide readers through the issues, making it accessible to a general audience. However, the inclusion of technical terms like 'WAC' without further explanation could confuse readers unfamiliar with pharmaceutical economics. Providing definitions or context for such terms would enhance comprehension.

Source quality

The article relies on general industry knowledge and publicly available reports about PBM practices and biosimilar approvals. While it references specific companies and their strategies, it lacks direct citations or quotes from authoritative sources such as PBM executives, healthcare professionals, or regulatory bodies. This limits the depth of the analysis and the credibility of certain claims. Including interviews or data from primary sources would enhance the reliability of the information presented.

Transparency

The article provides a good overview of the issues surrounding PBMs and biosimilars but lacks transparency in terms of sourcing and methodology. It doesn't specify how the information was gathered or whether there are any potential conflicts of interest. The absence of direct quotes or references to specific studies or reports makes it difficult for readers to assess the basis of the claims. Greater transparency regarding the sources of information and the author's affiliations or potential biases would improve the article's credibility.