Proactive PBM Oversight Protects Cost Savings During a Humira Biosimilar Transition

During a PBM transition, errors within a Humira biosimilar strategy cost three large employers a combined ~$750,000 in savings, which PSG quickly identified through Artemetrx and helped recoup.

The Challenge

In 2024, PBM approaches to Humira and their biosimilars began to diverge. High WAC and low WAC Humira biosimilar products were managed differently across PBMs, creating new operational risk during PBM transitions. This issue would not have existed even a few months prior, when strategies were more aligned across the market.

For these three employers, the intended approach after switching PBMs was clear: utilize the low WAC Humira biosimilar product to achieve the lowest net cost. However, within the first quarter, claims data showed that the high WAC product was being dispensed instead. Because this product was excluded from the formulary, it was not eligible for rebates and had a net cost 5x higher than the low WAC product. The financial impact was largely invisible without evaluating claim-level reporting. Members were not necessarily paying more, invoices looked reasonable on the surface, and standard PBM reporting did not surface the issue.

Without intervention, the employers would have continued to incur higher cost claims month after month with no clear signal that anything was wrong.

PSG’s Supporting Services

Artemetrx: An integrated platform that transforms data into intelligence, driving improved management of drug spend and trend across both the pharmacy and medical benefits.

Clinical Consulting: Our team of experienced pharmacists provides unbiased clinical expertise to help clients make informed decisions that optimize their plans.

Download Full Case Study

Standard reporting may not be enough as market complexity continues to grow. Download the full case study to learn how informed oversight through a combination of analytics, clinical insight, and operational follow-through has proven effective.