In the US, large healthcare insurers issue formularies which specify which version of a drug they will reimburse. Although insurers have not typically expressed preferences for small molecule generic drugs, they do have specific preferences for biosimilar drugs. This means providers must check separate formularies when treating patients with different insurance coverage and, if the insurer preferred version of the drug is not in stock, may need to custom order the drug in question or engage in non-medical switching.

To further evaluate the impact of insurer formularies on the work of healthcare providers, Health Affairs investigated coverage policies for pegfilgrastim [1], which is used to stimulate white blood cell production in patients receiving chemotherapy.

The authors looked at coverage policies for pegfilgrastim between October 2019 and March 2020 in the US, during which time there were three biosimilar versions available (Fulphila, Udencya and Ziextenzo) in addition to the originator (Neulasta).

They compiled formulary notifications to one health system from five commercial insurance plans — Aetna, Cigna, United Healthcare, Anthem and Blue Shield — which together cover around 40% of the health system’s cancer patients).

Products were categorized as preferred (drugs that must be tried before other products can be covered) or non-preferred (which can only be used when a preferred product has been tried and failed). As an example, UnitedHealthcare announced in 2019 that it would prefer the use of brand-name pegfilgrastim (Neulasta) over biosimilar versions [2].

The analysis showed a range of preferences across insurers, with no consensus on preference for either the originator or biosimilar version of pegfilgrastim, nor among the biosimilars. Preferences also changed over time, with Cigna changing Udenyca and Ziextenzo from non-preferred to preferred between October and March, for example.

The authors suggest that insurer preferences increase costs and make the work of hospital pharmacists more difficult, as pharmacies must stock several versions of the same product depending on insurer preferences at the time. They also say that the need to check patients’ insurance coverage introduces the potential for errors, particularly in the context of cancer treatment where providers must also review the chemotherapy drug used, its dosing, frequency and method of administration. There is also the potential for treatment to be delayed if the preferred drug is not in stock, which could be clinically dangerous. Furthermore, if a clinically equivalent but non-preferred version is substituted, it could lead to the patient paying out-of-pocket.

Overall, the authors suggest that insurer formularies reduce the ability of clinicians to choose the best treatment for their patient, while also preventing market competition from driving prices down.

To remedy this, the authors recommend that hospital committees decide which version of a drug be used for its patients. The authors also say that hospitals should be able to negotiate directly with manufacturers, which would reduce costs and generate savings to benefit patients and healthcare providers.

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References
1. Insurer formularies complicate the adoption of biosimilar cancer therapies. Health Affairs Blog, April 8, 2021. doi:10.1377/hblog20210405.345071
2. GaBI Online - Generics and Biosimilars Initiative. UnitedHealthcare to prefer brand-name pegfilgrastim [www.gabionline.net]. Mol, Belgium: Pro Pharma Communications International; [cited 2021 May 7]. Available from: www.gabionline.net/Biosimilars/General/UnitedHealthcare-to-prefer-brand-name-pegfilgrastim

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