Premera Formulary: Biosimilar Value, HCLV Drug Guidance, and More

Biosimilars

Biosimilars are highly similar versions of existing biologic medicines (known as reference products) that have already been proven safe and effective. Because biologics are complex therapies made from living cells, biosimilars must meet rigorous regulatory standards to demonstrate they have no clinically meaningful differences from the reference product in terms of safety, quality, and effectiveness. In practice, this means patients and providers can expect the same therapeutic outcomes they trust from the original biologic.

From a cost‑management perspective, biosimilars play a critical role in expanding access to high‑value therapies. By introducing competition into categories that have traditionally been dominated by single, high‑cost biologics, biosimilars help lower overall drug spend for health plans, employers, and patients. These savings can be reinvested to improve coverage, reduce patient out‑of‑pocket costs, and support broader access to innovative treatments.

For groups focused on balancing clinical excellence with financial stewardship, biosimilars represent a smart, sustainable solution. They allow decision makers to maintain high standards of care while managing budgets responsibly—without compromising patient outcomes. As adoption continues to grow, biosimilars are becoming an essential tool in delivering affordable, high‑quality care.

High-Cost, Low-Value Drugs

Understanding Premera’s High Cost, Low Value Drugs – applicable only to the Incentive formulary

Managing prescription drug costs while ensuring access to effective care is a shared priority. One of the ways Premera supports this balance is through the High Cost, Low Value (HCLV) Drug List that identifies medications that are:

• Significantly more expensive, and
• Not shown to provide meaningful clinical benefit compared to other available treatment options.

In many cases, lower‑cost alternatives—such as therapeutically equivalent medications or different formulations—are available and provide similar outcomes for most patients.

How does it work?

Medications are reviewed through Premera’s established clinical and formulary evaluation process, which considers:

• The strength and quality of clinical evidence
• Comparative effectiveness versus other therapies
• Overall cost and value

When a drug is designated as high cost, low value, it may be excluded from the formulary or subject to utilization management, depending on the plan design. Clinically appropriate alternatives remain available, and exception processes are in place when medication is medically necessary.

Example: If a high‑priced brand‑name drug enters the market but does not demonstrate improved outcomes compared to existing, lower‑cost therapies, it may be placed on the HCLV Drug List. In these cases, members and providers are encouraged to use effective alternatives that help reduce unnecessary spending without compromising care.

Key Takeaways

You can take a few simple steps to maximize the value of this program:

• Review your formulary to understand how HCLV drugs are handled under your plan
• Communicate with employees about coverage changes and available alternatives
• Partner with your Premera account team for education, resources, and benefit strategy support

Premera remains committed to helping you balance affordability, access, and quality. The High Cost, Low Value Drug List helps better manage pharmacy costs, supports evidence‑based prescribing, and promotes sustainable benefit designs over time. This is one of several tools designed to support smarter pharmacy spending while maintaining high standards of care.

Read the full formulary update.