Jeff Cohen, MD, and Alicyn Magruder, PharmD, BCACP, MSCS, discuss the best practices when switching to a biosimilar therapy, including patient education and when to consider an insurance appeal. [WATCH TIME: 7 minutes]
WATCH TIME: 7 minutes
The treatment paradigm for multiple sclerosis (MS) has come a long way since the early years of ABCR agents, with a therapeutic arsenal of disease-modifying therapies now numbering in the 20s. Yet, with all of the change that advances in pharmaceutical development have brought, there are still novel approaches being introduced—and perhaps the biggest recent introduction is biosimilars.
With the FDA approval of the first of these new products for MS in the fall of 2023, the era of biosimilar treatments has begun, and in this new era is a new challenge: education and awareness of these options, for both patients and clinicians.
In collaboration with the National MS Society, NeurologyLive® hosted a Roundtable Discussion focusing on this step forward for MS treatment, the changes that it will bring to care and the healthcare system as a whole, and the resources for the field to stay up to date on their use. Featured in the discussion are Jeffrey Cohen, MD, an MS specialist and director of Cleveland Clinic’s Mellen Center for Multiple Sclerosis Treatment and Research; Alicyn Magruder, PharmD, BCACP, MSCS, a clinical pharmacist at Mizzou Specialty Pharmacy within the Neurology and Sleep Disorders Clinic; and Sarah Anderson, PharmD, NBC-HWC, a pharmacist and director of Clinical Content and Resources on the Clinical Innovation and Strategy Team at the National Multiple Sclerosis Society.
Transcript below. Edited for clarity.
Matt Hoffman: When it does come to the actual process of potentially switching a patient to one of these biosimilar products, obviously there are a few things that could trigger that to happen or why it might be happening. I imagine a lot of it is coming from the payor side of things. When we're navigating that—particularly the cross-communication between the pharmacy side and the physician side—how do we engage with patients about this, if their payor does require them to either initiate one of these biosimilars or even potentially switch to it? Where does that conversation start, and how does that communication between the 2 major players on the clinical side of things, how does that happen?
Jeff Cohen, MD: I mean, currently, as you say, the main drivers of the use of biosimilars and generics have been the payors. We learned that that's what they're requesting, either at the time of prior authorization or, increasingly, sometimes when patients have already been on a brand product, we're informed that they need to switch to a generic or biosimilar. Generally, I would say I reassure my patients that it's going to be OK. Our experience, overall, has been very positive. But we also reassure them that we're going to monitor things closely, and if there are some anticipated issues, we'll deal with those, and if we need to appeal to go back to the brand product, we’re willing to do that. And we've had to do that occasionally, but overall, the experience has been positive.
Matt Hoffman: And then how does the pharmacist then play a role in support? There's a lot of conversation and education with the patient, but again, especially in an instance where there might be a need for appeal—I imagine that word might strike a little bit of, “Oh no,” in a patient's heart—how do we address that when we’re going from, “All right, I've been prescribed,” to now “I'm at the pharmacy” and that continuum of the patient experience?
Alicyn Magruder, PharmD, BCACP, MSCS: My clinic benefits from the fact that I'm in the clinic, so I get to have those conversations with the doctor. They're trained to let the patient know that we do have a benefits investigation before we know what can be given to the patient. But the biggest thing I tell the patient is the best drug is the drug that you have access to. And so, even though we prescribed a brand name medication, your insurance now wants the generic or the biosimilar, and we can talk about how we would prefer—not necessarily we as clinicians, but maybe the patients sitting there—the brand name, but you have to make them understand that the medication you have access to is the best medication. We have to make sure that you get the medication. We can fight insurance, but that can delay care, and so sometimes it's safer to pursue what insurance wants than to delay care, especially when we're dealing with natalizumab.
For me, my patients are most concerned when we switch. So, they've been established, and they've been doing well and they're like, “I'm doing well, why would somebody make me switch?” I don't have a hard time with patients going for a generic or biosimilar starting out. It's those people that say, “I got a letter from my insurance, and they say that that I can't have Tysabri [natalizumab] anymore.” Then what does that look like for them?
One, we've got to investigate what the access points are going to look like through the insurance and then their copay. A lot of times when we switched from branded medications, when there's a biosimilar or generic, they have copay programs, too—but not every time. Just because we've switched to a less expensive medication doesn't mean it's less expensive to the patient. Sometimes we do have to fight so that they can get something that is actually affordable to them. That's one that with fingolimod that I hit. Early on there, weren't copay cards (now there are), but in the beginning when we were switching, those patients were used to $0 copays and then they came back with $500 copays, like, “How can I afford this?” Once again, just making sure that patients understand that the best drug is the drug that they can get, and that they can get quickly if we're being forced to switch, especially in the setting of S1Ps [sphingosine phosphate 1 receptors] and natalizumab.
Matt Hoffman: I believe this isn't the case for natalizumab, but does that conversation at all come up—I imagine this is maybe the case down the road—in the instance of interchangeable biosimilars. I don't believe natalizumab is considered interchangeable, but in your experience, Dr. Magruder, has that been a challenge? Is understanding why this is the therapy they’re getting and really just stressing that access [a challenge]?
Alicyn Magruder, PharmD, BCACP, MSCS: I think just letting them know that insurance is going to dictate a lot of things and that we have to go that way [is important]. Sometimes it forces a new prescription and can even slow down the process, especially in settings where your pharmacist isn't the pharmacist in the clinic or they're coming from an outside pharmacy who is happy to ask the doctor, “Is it OK to switch to this,” and that can slow things down. Making sure that patients understand that this is a process that takes multiple team players and insurance. In my world, a lot of times insurance are the bad guys, but honestly, they are trying to do what is best for the whole insurance company as far as cost savings, so the patient needs to understand why that’s happening. So, it’s just being able to explain that to them. A lot of time I talk to them about how contracts work and why they paid for brand name for a long time and now they're not—that kind of thing.