1. Benchmark your metrics and dig in.

Determine your current GSM: what percent of multi-source brand drugs are being substituted with generics?
Calculate your SBSR for biosimilar opportunities: among biologic drugs with approved biosimilars, what percent are filled with the biosimilar?
Ask your PBM or consultant how both GSM and SBSR are defined. Are vaccines, medical-benefit drugs, or certain specialty classes excluded? Clarity on methodology ensures accurate comparisons.
Compare your results to aspirational targets (for example: GSM > 99%).

2. Review and align formulary/benefit design.

For generics: exclude brands when generics exist, set copays or coinsurance so generics are clearly the value pathway, and apply generic-first step therapy where clinically appropriate.
For biosimilars: implement a "biosimilar-first" approach. This could include giving biosimilars preferred placement on the formulary, gradually removing the reference product, offering lower copays for biosimilars, or placing the brand on a higher cost tier.
Engage your PBM to demonstrate net savings: what are the savings after rebates / spread / pricing adjustments, not just list-price differential?

3. Engage providers and members.

Clinician and patient awareness are critical for biosimilars. Some providers may hesitate to switch stable patients, and some patients may worry about the effectiveness of the switch. Clear education and communication can help overcome these concerns.
Establish pathways such as prior authorization or step therapy that facilitate switching to biosimilars when clinically appropriate, balancing continuity of care with cost savings.

4. Monitor pipeline and opportunities.

Monitor upcoming patent expirations and biosimilar launches for key biologics such as Xolair (for asthma and allergy), Eylea (for ophthalmic conditions) and Simponi and Orencia (for autoimmune conditions).
Identify when opportunities to shift to biosimilars arise and be prepared to adjust plan or benefit designs accordingly.
Anticipate potential adoption barriers like provider hesitation, PBM formulary delays, interchangeability issues, or state regulations and factor them into your planning.

5. Integrate into your broader pharmacy-strategy lens.

Generics and biosimilars are part of a broader set of levers: specialty-drug management, GLP-1 trend mitigation, medical-benefit pharmacy migration, and rebate optimization.
Avoid viewing generics and biosimilars in isolation. They deliver value only when considered within the full context of overall drug-spend dynamics and plan design.

Turning potential into real results

Generics and biosimilars aren't just cost-saving tools; they're essential levers for keeping prescription benefits sustainable. With specialty drug costs rising and rebate structures growing more complex, underutilizing these options puts plans at greater financial risk.

Instant Insights /

Are biosimilars and generics living up to their promise?

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