Learn how to stay ahead of payer policy changes in biosimilar coverage in oncology pharmacy practice

With the rapid pace of change in the design of biosimilar payer benefits, efforts to stay regularly informed of policy changes in advance are becoming critical to patient care.

There has been a significant gain in clinical confidence in the process of demonstrating biosimilars, explained panel moderator Jorge García, PharmD, MS, MHA, MBA, FACHE, during a session at the 2022 ATOPP Summit. , the challenge remains to learn how to overcome and manage the various obstacles and opportunities that the evolution of biosimilars continues to present to pharmaceutical practices in oncology.

“One of the biggest challenges we face is really preparing and staying ahead of the design of payer benefits and the changes that happen throughout the year, sometimes on a quarterly basis. “, Garcia said.

In light of this rapid pace of evolution of biosimilars in terms of the design of payer benefits, García noted that finding a method to stay ahead of policy changes that may ultimately have an impact on downstream operations.

Panel participant Mandy C. Leonard, PharmD, BCPS, system director of medication use policy and formulary management at the Cleveland Clinic, noted that at her institution, due to the ever-changing nature from the design of biosimilar payer benefits, pharmacists in his organization have had to learn how to adapt to these frequent changes by monitoring what is happening at the Cleveland Clinic, not only from an inventory standpoint, but also from a form management perspective.

“I think we would all like to say that if we could select a biosimilar to a reference product in our organization, that would be best for us in terms of controlling many aspects of it, but that’s not always the case,” Leonard said. “So I think some of the hard things over the last few years after some of the biosimilars have been introduced is how do you deal with all of that, and I think one of the biggest lessons that I learned is that I thought we were doing such a fantastic job of streamlining biosimilars within our organization once we got buy-in from medical staff, but then I learned that it could have an impact on patient care because [of issues] on the other side of things with insurance.

Also, pharmacists do not always know when there will be a change in payer coverage. Leonard noted that in light of this, it’s important to work with a strong team within the facility who can help ensure the pharmacist stays on top of these coverage changes. Whether this team is part of billing, marketing, or network strategy, they can help pharmacists assess in advance what they are going to do about coverage changes in the electronic health record (EHR) so to help providers to their end.

Panel participant Kenneth Komorny, PharmD, BCPS, the Chief of Pharmacy at Moffitt Cancer Center, noted that at his facility they have embraced the managed care service for effective collaboration on this front at Moffitt Cancer Center and meet on a quarterly basis to ensure a high level of communication regarding changes in biosimilar payer coverage.

“We’ve tried to be proactive, combing them through payor policy changes to make sure we’re on top of that. Otherwise, you’re surprised,” Komorny said. “So they maintain a spreadsheet for us, and we try to capture the majority of them. They have hyperlinks on them; it’s a living document, and we can click on it and find out in real time what the insurance policy [a biosimilar].”

With the living document noting payor policy changes in real time, Komorny noted pharmacists at Moffitt Cancer Center can create a one-page guide for pharmacy staff to ensure everyone stays informed. medications available. In addition, pharmacists note the main payers in the system as well as the different products, and whether or not they are covered by the insurance company, and whether they are on formulary or off formulary.

“It works as a guide for pharmacy staff to know which drugs we have available and which ones we don’t. But again, it’s really about reaching out to your managed care department and your payment strategies department and working with them to create this [spreadsheet]. We don’t have the expertise to comb through these insurance policies — they’re very, very long,” Komorny said. “So we kind of lean on them to do that part, and then we wrap it up from a pharmacy perspective.”

Komorny noted that even with this living document noting payer policy changes that impact pharmacist practice, it also remains important to conduct benefit surveys for each patient and service date as policies can change from quarter to quarter.

“In fact, that’s what we see in practice,” Komorny said. “We also have patients changing jobs in Florida, we have temporary Medicaid, where patients may have insurance one month but not the other. So it’s a lot of work to stay ahead of the politics and then investigate the benefits every time.


García J, Leonard MC, Komorny K, Rozenblyum E. Real impact of biosimilars on healthcare costs. San Diego, CA: ATOPP Summit 2022; July 16, 2022.

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