Jun 18, 2018
In
just a little more than six months, biosimilars reimbursed in Medicare Part D
will get a boost from legislation passed earlier this year. Plans and patients
also stand to win, but manufacturers, not so much.
In
Part D, beneficiaries consistently pay a 25% cost share until they hit the
catastrophic phase, when their responsibility decreases to 5% of the drug.
During the initial coverage period, plan sponsors are responsible for 75% of a
drug’s cost; during the “donut hole” coverage gap, brand-name drugs’ manufacturers
must pay 50% of the drugs’ cost, while plan sponsors’ responsibility drops to
25%. Biosimilar manufacturers, by contrast, are excluded from having to provide
this discount, leaving plan sponsors’ responsibility at 75%.
Yet
as of 2019, biosimilars will be treated the same as brand-name drugs rather
than as generics in the coverage gap. The legislation also closes the Part D
coverage gap discount program in 2019 as opposed to 2020.
Reclassifying
biosimilars could impact physician prescribing, contend consultant Jim Martin,
Ph.D., and Elan Rubinstein, Pharm.D., principal at EB Rubinstein Associates.
“Equalization of patient out-of-pocket costs in the donut hole may also make it
more likely that Prescription Drug Plans will favor biosimilars in their drug
formularies,” they add.
It
will be interesting to see how manufacturers with branded medications will
respond to the changes and how plans respond to manufacturers’ moves, says
Andrew Cournoyer, R.Ph., vice president, director, payer access solutions at
Precision for Value. “Will [manufacturers] offer additional rebates to
incentivize payers to continue covering” the branded products? “Will plans look
at implementing preferred and not preferred specialty tiers?” he asks.
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