Copay Plan Design Considerations For Specialty Generic and Biosimilar Drugs

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

With the most recent launch of both a generic and a biosimilar for two different highly utilized expensive specialty drugs (Copaxone and Neupogen respectively), it is very important that Plan Sponsors providing pharmacy benefits to their employees and members understand, not only the specific discounts that are being applied to these generic and biosimilar equivalents by your PBM, but also at which member copay tier your PBM will be adjudicating the claim.

Copaxone is available in both a 20 mg and 40 mg strength, with the 40 mg dosage less frequent per week and thus a higher adherence rate. These drugs are Brand Specialty drugs, for which pharmaceutical manufacturers provide rebates to the PBMs, which are shared at certain levels depending on your level of expertise in negotiating your PBM Agreement. Also of interest is that the manufacturer, Teva, moved two thirds of all prescriptions to the Copaxone 40 mg, which is available ONLY as a brand, to maintain market share. 

On April 16, 2015 Copaxone 20 mg Brand was released as an A Rated Generic of Copaxone 20 mg, and because Copaxone is a biologic drug, the generic drug has a different name which is Glatopa, manufactured by Sandoz. As more generics of Copaxone 20 mg come to market those drugs will also have different generic names.

The AWP for the following drugs as of September 25, 2015 is as follows:

• Copaxone 20 mg: $244.42 per unit or $7,332.60 (30 mL syringe)
• Copaxone 40 mg: $500.80 per unit or $6,009.60 (12 mL syringe)
• Glatopa 20 mg: $216.41 per unit or $6,492.41 (30 mL syringe); however, at a MAC price with certain PBMs based on how you negotiated the PBM contract and thus, the AWP would be around $6,000 or very similar to Copaxone 40 mg.

If you have a three tiered copay plan design: Generic, Preferred Brand, Non Preferred Brand, the Glatopa copay will defer to the generic copay, which is the copay you have set for typically “traditional” drugs and not high cost specialty drugs. If you have a four tiered copay plan design, which is similar except that there is an additional copay for “all” specialty drugs, Glatopa would still defer to the generic copay. If you had a five tiered copay plan with two copays for “all” “specialty drugs”: Preferred Specialty and Non Preferred Specialty, the lower cost A Rated Generic, Glatopa, would defer to the Preferred Specialty versus the "traditional drug" Generic copay and the higher cost Brand, Copaxone 20 mg, would defer to the Non Preferred Specialty copay, which is the appropriate cost share since the generic of a specialty drug is still in the thousands of dollars range.

As mentioned above, some PBMs have already applied a MAC to Glatopa dropping the cost by approximately $1,100 to $1,300 less expensive than the Copaxone 20 mg brand. HOWEVER, IF THE COPAY LEVEL FOR THIS NEW CATEGORY OF HIGH COST SPECIALTY GENERIC IS NOT IN YOUR PLAN DESIGN, YOUR PLAN COULD BE LOSING NOT ONLY THE COST SAVINGS, BUT ALSO THE INCENTIVE FOR THE MEMBER TO TALK TO THE DOCTOR ABOUT THE LOWER COST ALTERNATIVE.

The same logic exists for biosimilars of high cost specialty brand drugs, which are not interchangeable and are subject to the doctor’s prescribing along with state and federal laws. On September 3, 2015, Zarxio, the biosimilar of Neupogen was launched. Though conceivably having a lower AWP as compared to the brand Neupogen, PBMs receive rebates for the brand and are likely not to lower the member copay for biosimilars so quickly. In a recent PBM survey by PBIRx, PBMs vary as to the discounts they are applying to these new specialty generic and biosimilar drugs, as well as to which member copayment tier will apply.

PBIRx has been providing pharmacy benefit consulting and auditing for 25 years and is constantly on the cutting edge of monitoring new drugs and existing drugs to work with our clients to lower costs on a continuum. For more information related to generic and biosimilar discounts and copays, please contact us at (888) 797-2479.