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Savings for Plans and Patients with CVS Humira Formulary Changes

biosimilar blocks

First launched in 2003, Humira has experienced more than two decades of unprecedented marketplace dominance. A mainstay of treatment for several autoimmune conditions, National Cooperative’s members spend more on this drug than any other under the pharmacy benefit. Last year, several biosimilars for Humira entered the marketplace. The Cooperative, like many others, has anxiously awaited the arrival of new products that could create sufficient marketplace competition to help lower costs.

We were excited that CVS Caremark (CVSC) began the new year with the announcement of an important formulary change: removal of Humira from several formularies in favor of biosimilars, resulting in a projected 27% net savings over 2022 spend in the autoimmune class.

Effective April 1, 2024, CVS Caremark standard control, advance control, and value formularies will begin to prefer adalimumab biosimilars Hyrimoz and adaliumumab-ADAZ.

Because these biosimilars will require new prescriptions at the pharmacy, CVSC is providing extensive proactive communications via various channels to both patients and providers. This approach will help patients and providers understand the biosimilar alternatives and facilitate a smooth transition prior to 4/1. Provider messaging will take place via RxChange, a new communication platform within CVS Specialty that allows prescribers to view and approve the formulary change in advance of 4/1. It is anticipated 95% of all claims going through CVS Specialty will be switched using the new RxChange process. In addition, because the vast majority of our members have opted to utilize CVS Specialty for their plan participants, we believe most Cooperative members will be proactively managed through RxChange.

In addition to RxChange, there will be proactive texting and lettering along with all the standard formulary notification processes CVSC has utilized in the past for formulary changes. As always, will have educational materials regarding the change. Additionally, the National CooperativeRx in-house specialty prior authorization program is uniquely positioned to further encourage and assist plan providers and members with the switch.

National CooperativeRx is very supportive of the use of biosimilar medications. Biosimilars are highly similar to branded biological medications already on the market. The FDA has indicated that biosimilars are safe and effective. Biosimilars are already being utilized by Cooperative members. As biosimilars gain acceptance and create competition in the marketplace, we anticipate significant savings can be achieved with strategies that promote their utilization. This move by CVSC will help propel the marketplace forward, and we expect to see similar strategies for other biosimilar products in the future.

The autoimmune class of drugs is competitive, and many factors were assessed by CVSC prior to this decision, including sufficient supply, various formulations, and availability of copay assistance to support the needs of patients.

Ultimately, National CooperativeRx plan sponsors will see lower net costs. However, a notable change for plans will be how they see the savings. With this formulary change, CVSC will be preferring a lower list price product with lower, or no, rebate value. Rather than wait several months to receive the rebate value, plans will experience lower ingredient costs at the point of fill in exchange for reduced rebate payments. At current interest rates, the time-value-of-money calculation alone will put plans ahead of where they are today.

Overall, patient impact will be low and cost savings will be high. In 2023, only .2% of patients were on Humira, but gross spend exceeded $49 million through Q3. As always, National CooperativeRx will monitor this development to provide oversight and maximize the savings realized by our members.

Humira will remain a preferred brand for plans who elected a “Choice” or opt-out formulary in 2023. As part of the option to stay with high list priced products and maintain higher rebate payments, these plans will not require members to switch to Humira biosimilars and they will not experience the same level of savings.

National CooperativeRx is supportive of the biosimilar-first formulary strategy, and we believe the big PBMs should aggressively adopt biosimilars to induce marketplace disruption. The current biosimilar market is $10B and is expected to be close to $100B by 2029, so adopting this strategy will allow plan sponsors and their members to benefit for several years. While we are supportive of lower prices at the point of sale in favor of reduced rebates, we are also supportive of plans having a choice in the approach that is best for their population.

If you have questions about this change, or anything else, please reach out to your National CooperativeRx account representative.

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