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Use of Step Through Policies for Competitive Biologics Among Commercial US Insurers

Summary

Avalere evaluated payer policies for biologics when biosimilars are available.

Biosimilar product uptake has been relatively slow in the United States (US) as compared to other markets in developed countries. To understand coverage decisions and formulary design for biologics when biosimilars are available, Avalere assessed coverage and formulary design for the top 25 payers in the US (about 189M covered lives) using publicly available coverage policies.

Key findings of our review include:

  • 78% of plans (representing 81% of covered lives) with publicly available medical coverage information require patients to step through one version of a DMARD (which may be a biologic or generic) before the subsequent treatment; and
  • 56% of plans (representing 76% of covered lives) with publicly available formulary information use tiering to designate preference for one version of pharmacy biologics or biosimilars over the competitor.

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