Blue Shield of California challenges PBM model to lower cost of Humira biosimilar
The lower price for members is due to a new Pharmacy Care Reimagined model that unbundles the traditional PBM model, company says.
Photo: Guido Mieth/Getty Images
Blue Shield of California has cut the price it will pay for a biosimilar of the drug Humira.
Blue Shield will purchase the medicine used to treat certain autoimmune and inflammatory diseases, such as arthritis, Crohn's disease and ulcerative colitis, at a net price of $525 per monthly dose, compared to the market net price of Humira at $2,100.
To date, Humira is not one of the drugs that is part of the Centers for Medicare and Medicaid Services Drug Price Negotiation Program.
WHY THIS MATTERS
Blue Shield spends more on Humira than any other drug for its members, processing about 40,000 Humira prescriptions annually, the company said.
After two decades of market exclusivity and $200 billion in sales, Humira's patent exclusivity expired in January 2023, which allowed lower-cost alternatives – known as biosimilars – to become available, Blue Shield said.
However, the price has not come down to the extent it should in a functioning market, limiting widespread adoption, the company said.
Blue Shield said its lower price was made possible by its new Pharmacy Care Reimagined model, which provides members with better access to biosimilar medications. Pharmacy Care Reimagined unbundles the traditional pharmacy benefit manager model by eliminating the incentives that encourage higher list prices, Blue Shield said.
Blue Shield and drug manufacturer Fresenius Kabi, an operating company of Fresenius, and Evio Pharmacy Solutions, have eliminated the markups found in the traditional PBM model.
Starting on January 1, 2025, most Blue Shield commercial members using Fresenius Kabi's adalimumab-aacf will pay $0 out of pocket.
Blue Shield announced its Pharmacy Care Reimagined initiative last year, and this is the first time it is being used for a Humira biosimilar, the insurer said.
"With a looming 'biosimilar cliff' of multiple lower-cost biosimilar drugs about to enter the market, this move to transparent net pricing sets an important precedent and path forward for the rest of the market," Blue Shield said.
THE LARGER TREND
PBMs have come under scrutiny from Congress and the Federal Trade Commission, receiving much of the blame as the middlemen who increase the cost of drugs for their own profit.
The FTC began investigating PBMs in 2022 to examine their impact on prescription drug prices and access. The FTC's Interim Staff Report, released in July 2024, found that PBMs are "powerful middlemen" that inflate drug costs and harm local businesses.
The FTC also announced it was preparing to sue the largest three pharmacy benefit managers over their negotiations for the price of drugs, including insulin, according to The Wall Street Journal.
Blue Shield of California is a tax-paying, nonprofit, independent member of the Blue Shield Association with more than 4.8 million members, over 7,100 employees and more than $25 billion in annual revenue.
ON THE RECORD
"We will no longer take part in a pharmacy system that is designed to maximize the profit of participants instead of the quality, convenience, and cost-effectiveness for consumers," said Paul Markovich, CEO, Blue Shield of California. "Every employer, health plan and payer should be asking – and challenging – their pharmacy benefit managers to offer clinically effective and lower cost alternatives at a transparent price. This is why Blue Shield decided to rebuild our pharmacy care system – so we can get medications to the right people, at the right time, at the right price."
Email the writer: SMorse@himss.org
