It is one of our ongoing goals to reduce drug spend and improve health. As part of these efforts, we routinely evaluate new medications to market, such as biosimilars. A biosimilar is a biological product highly similar to an existing U.S. Food and Drug Administration (FDA) – approved reference product. Biosimilars have no clinically meaningful differences from reference products and are typically available at a discounted cost.
Cigna evaluates each biosimilar individually as it comes to market. There are 28 biosimilars approved by the FDA and 18 are available on the market today.1 We examine clinical safety and efficacy data, the conditions that are treated, and market factors. Such factors include costs and market share of the reference product compared with other biosimilars, as well as patent expirations for other products. We assess the affordability opportunity of each biosimilar to determine the lower-cost coverage option. Our goal is to use the least costly alternative with a benefit design to support it.
Market launch and uptake of biosimilars has been relatively slow due to multiple factors, including patent litigation, pricing strategies by both biosimilar and brand drug manufacturers, provider familiarity and experience with biosimilars, concerns about moving a customer with a chronic condition to an alternative product, and ongoing development of FDA regulatory guidance.
After considering all these factors, we arrive at a variable approach that determines the lowest cost option for our clients and customers. The possible preference options are to:
We predict that, over time, the biosimilar market will help reduce the rapidly increasing cost of specialty drugs through healthy competition. We continue to study it carefully and create strategies to prefer coverage for the biosimilar or reference product, as appropriate.
1. FDA’s Purple Book: Database of Licensed Biological Products, September 2020.
*Health benefit plans may be different, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and be medically necessary. If your plan provides coverage for certain prescription drugs with no cost-share, you may be have to use an in-network pharmacy to fill the prescription. If you use a pharmacy that does not participate in your plan’s network, your prescription may not be covered or reimbursement may be limited by your plan’s copayment, coinsurance or deductible requirements. Look at your plan documents for more information about your plan’s prescription drug coverage.
**If a provider believes any of the products that will no longer be covered as preferred options are medically necessary, Cigna will review requests for a medical necessity exceptions. Providers can submit requests for medical necessity review through their electronic health record or electronic medical record system or through CoverMyMeds® or Surescripts®.
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. Some plans require use an in-network pharmacy for prescriptions to be covered. Coverage is subject to any plan deductible, copayment and/or coinsurance requirements. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and complete details of prescription drug coverage, contact a Cigna representative.
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