Balancing Continuity of Care and Budget:
Nearly 80% plan savings through strategic biosimilar adoption
The Challenge
A small employer group faced significant specialty drug costs driven by a handful of high-cost claimants. Among these members was an individual receiving Stelara® (ustekinumab), a specialty medication associated with substantial annual pharmacy spends.
As specialty drug costs continued to climb, the employer sought opportunities to manage spend without disrupting quality of care or member outcomes.
The Solution
As part of Pharmacy Benefit Dimensions’ (PBDRx) ongoing clinical and formulary management strategy that prioritizes generic and biosimilar medications whenever available and clinically appropriate, a Stelara® biosimilar was added to the group's formulary. Prior to its addition, PBDRx delivered the client with a formulary transition plan that included communication at both the group and member level. To further avoid disruption, members were provided detailed instructions on how to engage with their providers and pharmacy to ensure a successful, seamless transition to a lower-cost biosimilar alternative.
The impacted member successfully transitioned from Stelara® to the biosimilar therapy without interruption in treatment, demonstrating how proactive clinical management can help balance cost containment with continuity of care.
The Results
Impact at a Glance
- Successfully transitioned a member from Stelara® to a clinically appropriate biosimilar
- Reduced annual drug spend by approximately $95,000
- Maintained member access to necessary treatment while improving affordability for both the plan and the member
The PBDRx Difference
PBDRx firmly believes that biosimilars are among the most impactful savings opportunities we can employ for employer-sponsored health plans seeking to drive down specialty pharmacy costs. Through proactive formulary management, clinical oversight, and member support, employer groups can realize substantial savings while preserving high-quality care for their members.
This case demonstrates how a single biosimilar conversion can generate a meaningful financial impact for a health plan, allowing employers to reinvest savings into broader benefits and long-term healthcare sustainability.
Questions
For more information on how you can gain greater control and cost savings on your prescription drug program, call (716) 635-3578 or email PBDSales@pbdrx.com.
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Our 25 years of experience in prescription drug benefit management provides the edge you and your clients need to manage expenses now and in the future.