Spotlight on Market Access

As fiduciaries, employers must act in the best interests of their employees and plan, but when it comes to biosimilars, some are not fully promoting them over higher-cost, rebatable reference drugs. During a recent webinar hosted by Midwest Business Group on Health (MBGH), employers including United Airlines and Caterpillar Inc. shared details of their successful efforts to move employees onto the cost-saving drugs.

MBGH also unveiled an Employer Action Brief on biosimilars with the same title as the webinar: Improved Adoption of Biosimilars by Employers Matters.

Removing Medicare Part D copay amounts for low-income beneficiaries significantly enhanced medication adherence, according to a Wakely report. As the CMS Center for Medicare and Medicaid Innovation ends the Value-Based Insurance Design (VBID) model later this year, these findings highlight the “compelling need for both state and federal policymakers to explore new strategies or incentives that enable MAOs to continue offering similar benefits” and improve outcomes to members with specific socioeconomic statuses, Wakely observed.

Beginning in 2021, Medicare Advantage plans were allowed to waive Part D cost-sharing amounts for select members through the VBID model. As of 2025, 62 MA organizations are offering that benefit for their Dual Eligible Special Needs Plan (D-SNP) members. D-SNP members who were eligible for the benefit had $0 copays on all covered drugs, through all phases of coverage.

A recent trend among pharmaceutical manufacturers has been restructuring the role of health economics and outcomes research (HEOR) teams within organizations. Rather than leaving them as standalone groups, many have been absorbed into other parts of the company, including medical affairs and market access. Companies can take various steps to make sure their evidence generation evolves with industry changes, meeting the needs of various stakeholders.

John Ross Maclean, M.D., Ph.D., executive vice president and head of medical affairs at Precision AQ, points to three reasons why the role of HEOR within pharma organizations has changed. The first he attributes to “tension between the science vs. the deliverable.”

UnitedHealth Group's UnitedHealthcare is the largest insurer in the U.S., enrolling nearly 46 million lives. In addition to health insurance, United's health services unit, Optum, powers pharmacy benefits management, specialty drug management, care delivery, population health services and data and analytics. This was further fueled by the company's 2022 acquisition of Change Healthcare, which gave United unprecedented insight into patient, claims and outside payer data. United and Optum arguably set the trend toward increased payer integration, fueling a wave of consolidation that sparked CVS Health's purchase of Aetna, Cigna Corp.'s acquisition of Express Scripts and Elevance Health's launch of Carelon.

A recent executive order from President Donald Trump laid out a host of directives with the goal of lowering drug prices and increasing transparency from PBMs. But experts tell AIS Health that the PBM-related goals are not yet very clear. 

The April 15 order notes the first Trump administration’s efforts, such as drug price transparency rules, encouraging development of generic and biosimilar drugs, and requiring that “government-mandated discounts” are passed through to patients. Trump then said that former President Joe Biden’s administration “reversed, walked back, or neglected many of these initiatives” and signed the “misnamed” Inflation Reduction Act (IRA) into law. While the executive order said the Medicare Drug Price Negotiation Program has a “commendable goal” of reducing Medicare drug prices, “its administratively complex and expensive regime has thus far produced much lower savings than projected.”