Adalimumab

Optum Rx prefers Amgen’s Amjevita over Sandoz’s Hyrimoz and Cyltezo on its 2025 commercial formularies, aiming to reduce costs and improve affordability. Humira remains on the formulary but with stricter controls. Biosimilars, including Humira’s, have struggled with adoption despite cost savings potential. Optum Rx also adds and removes various oncology and CNS medications for 2025.

Optum Rx prefers Amgen’s Amjevita over Sandoz’s Hyrimoz and Cyltezo on its 2025 commercial formularies, aiming to reduce costs and improve affordability. Humira remains on the formulary but is subject to prior authorization. Biosimilars have struggled with low adoption despite cost advantages, but large PBMs like CVS Health are shifting towards biosimilars. Optum Rx also adds and removes various oncology and CNS medications from its 2025 formulary.

U.S. patients gained access to lower-priced Humira biosimilars in 2023, but rebate practices by drug makers and PBMs limit competition, keeping out-of-pocket costs high. CVS Caremark and Express Scripts steer patients to preferred, not necessarily cheapest, biosimilars, preserving rebate-like strategies. Despite biosimilar market share growth, originator Humira still dominates with 82% share, contrasting with Europe's 65% five years ago.

Regeneron loses bid to block Amgen's Eylea biosimilar, plans appeal; Prime Therapeutics adds low-cost Humira biosimilars; FDA and EMA accept Alvotech's denosumab biosimilar for review.

Formularies have become significant barriers to realizing biosimilars' cost-saving potential, with inconsistencies in placement and rebate structures complicating adoption. Despite lower-cost biosimilars entering the market, formulary contracts and behavioral psychology hinder quick adoption, leading to potential savings remaining uncaptured. Recent shifts by PBMs like CVS Health and Optum show slow progress towards biosimilar preference, but systemic changes are needed to fully leverage their benefits.

Blue Shield of California will offer Idacio, an adalimumab biosimilar, at 75% less than Humira. This collaboration with Fresenius Kabi and Evio Pharmacy Solutions aims to reduce costs and improve access to biosimilars, with nearly all patients paying $0 out of pocket starting January 1, 2025.

Biosimilars are FDA-approved biologic medications highly similar to reference products, offering competitive pricing and expanding patient access. Between 2015-2023, biosimilars provided nearly 700 million therapy days without unique clinical challenges. The US biosimilar approval process is expedited, focusing on similarity to reference products. Interchangeability designation allows biosimilars to be substituted without prescriber intervention. President Biden's FY 2025 budget proposes unifying biosimilar and interchangeable standards. As of July 2024, the FDA has approved 56 biosimilars, including 10 adalimumab biosimilars. Biosimilars contribute to cost savings and market competition, with projected market growth to $129 billion by 2027. Policy changes, like CMS's temporary payment increase for biosimilars, aim to enhance accessibility. Health care systems like Providence St. Joseph Health have successfully integrated biosimilars, achieving significant cost reductions.