Impact of discordant preferred drug status between hospitals and payers for chemotherapeutic biosimilars

Abstract

Background

With increasing numbers of FDA approved biosimilars, and the expected advantages of lowering United States (U.S.) healthcare and patient out of pocket costs, questions remain regarding the impact of payers designating their preferred formulary drug(s).

Objective

To assess the financial impact to health-systems of chemotherapeutic biosimilars, specifically trastuzumab and bevacizumab, and its reference product utilization when a payer designates their preferred product(s) that is(are) different than the health-system's preferred formulary product.

Methods

This study is a retrospective review of insurance denials for orders of trastuzumab, bevacizumab, and their respective biosimilars, prescribed based on National Comprehensive Cancer Network (NCCN) guidelines and standards. The primary outcome was the financial impact of utilizing multiple products due to the payer's preference measured by cost to the hospital. The secondary outcome was the turnaround time required due to resubmission process and new financial clearance once the initial biosimilar authorization was denied.

Results

18 patients out of 452 (4%) patients, who received trastuzumab or bevacizumab treatment, were denied for hospital preferred biosimilar product and switched to the patient's insurance mandated biosimilar product. This resulted in a 1.28% increase in hospital actual acquisition costs. Impact on administrative time included a total of additional 70 h of IT time, 10.5 h of pharmacist time, and 18 h of patient access coordinator processing time.

Conclusion

The results of this study demonstrate the added burden to include financial and operational impacts on healthcare systems to continue to operate functionally for the utilization of multiple biosimilar products, as dictated by the patient's insurance plan. Further research is required to describe the impact to patients from their medical insurance plans that restrict biosimilar coverage to limited products.