Dec 18, 2024
Biologics are powerful drugs made from living organisms used to treat a range of complex conditions, from autoimmune disorders to cancer. A biosimilar is an alternative version of a biologic nearly identical in chemical structure, clinical function, and effectiveness. Just as you might take a generic version of a brand name prescription drug – think, ibuprofen instead of Advil – a doctor could prescribe a biosimilar in place of a biologic to treat a complex medical condition.
Matthew Gibbs, Blue Shield’s VP for Pharmacy Transformation, explains biosimilars and why they’re essential to bringing down pharmacy costs overall in this article and video.
Humira: Demonstrating the potential cost-saving impact of biosimilars, Blue Shield announced earlier this fall a collaboration with Fresenius Kabi and Evio Pharmacy Solutions to purchase FDA-approved Humira biosimilar (adalimumab-aacf) for $525 per monthly dose, compared to the market reported net price of Humira at $2,100.
Humira will no longer be included in the formulary beginning January 2025. IFP and/or Commercial members with an existing prescription for Humira are being notified of the change and encouraged to switch to the biosimilar but are not required to do so. Commercial members switching to the biosimilar (adalimumab-aacf) will have $0 cost share. If they continue with brand name Humira, their Tier 4 prescription drug benefit cost share (up to the max copay, $250 for most plans) will continue according to their plan benefits in 2025.
For commercial members newly prescribed Humira in 2025, their provider must request a medical exception necessity to the formulary coverage. If the exception is APPROVED, the Tier 4 cost share up to the max copay ($250 for most plans) could apply. If the exception request is not approved and the member wants to take Humira, they will be responsible for the full cost of Humira.
For Medicare plan members in 2025, Blue Shield is pursuing a biosimilar-only strategy with Hadlima as the formulary biosimilar for Humira. Regulations, specialty network, and pricing differ between Commercial and Medicare lines of business and these differences factored into the decision to have separate biosimilar strategies by line of business. Both Hadlima, the biosimilar selected for Medicare formularies and adalimumab-aacf, the biosimilar selected for the Commercial formularies, are equally safe and effective.
For more Blue Shield pharmacy news, read:
Optimizing Blue Shield's Retail Pharmacy Network
New Member ID Cards
