If you’re a plan sponsor, you’re probably familiar with the drug Humira. That’s undoubtedly because it appears toward the top of your list of costliest drugs. Well, that might change soon. Or maybe not. It’s tough to tell.

In a recent development that may have escaped your attention, Cyltezo became the first FDA-approved interchangeable biosimilar for Humira. It was judged highly similar to, and with no clinically meaningful differences from, a biological product already approved by the FDA (Humira).

Like the current brand/generic system, starting on July 1, 2023, a pharmacist may automatically substitute the alternative prescription without prescriber (physician) involvement. And while Cyltezo is the first, five more manufacturers are preparing their own launches ― creating the ideal competitive environment to drive more fair and reasonable costs.

After all, competition in Europe already drove AbbVie to cut Humira costs dramatically. So, one would naturally assume this bodes well for more competitive pricing in the U.S., right? Maybe not. Things (pricing, distribution, advertising, etc.)  are a little more complicated here.

To stay a step ahead of the more advanced games stateside, plan sponsors need to be putting safeguards in place now. Need proof? Market manipulation games in the U.S. are already happening.

As you know, the “Big 3” PBMs already have programs in place to prop up preferred brands or “reference” products touting the “lowest net cost.” They have forced manufacturers to provide deeper discounts on over-inflated list prices and demanded larger rebates.

Unfortunately, these distribution incentives do not “pass through” 100% to the plan and patient, but rather are used to help the PBMs meet their contractual rebate guarantees. AbbVie has already worked with PBMs to tie Humira pricing and future rebates to each PBM’s willingness to shift its formulary preference and clinical criteria to two other AbbVie products ― Rinvoq and Skyrizi. Mass provider and patient advertising campaigns are already in full swing to change the prescribing patterns ahead of the biosimilar launch.

Whether reviewing pharmacy or medical benefits, auto-immune disorders are always a major spend driver. That’s why having your advisor, PBM, and TPA partners aligned with your plan’s interest ― not their own ― has never been more critical.