Your plan just needs an easy way to capture them.
The biosimilar opportunity is not a rumor. The drugs exist, the FDA has approved them, and the cost differences between a biologic and its biosimilar equivalent are significant. Projections from AJMC put U.S. biosimilar savings between 2021 and 2025 at $38.4 billion and that figure assumes conservative uptake. The ceiling, under stronger adoption conditions, is dramatically higher.
So, the question for any CFO looking at pharmacy spend is not whether biosimilar savings are real, but why so little of that value shows up in claims?
The answer lies in a layered barrier across the whole healthcare system from formulary mismatches to physician resistance.
Biosimilars are FDA approved. That does not mean they are prescribed.
More than a dozen biosimilars for Humira are now on the market. Eight Stelara biosimilars launched in January 2025 alone. The pipeline for additional specialty drug biosimilars runs well into 2026 and beyond. From a formulary standpoint, most plans have at least nominal biosimilar coverage but that does not mean the biosimilar is visible to prescribers.
In a recent peer-reviewed survey of outpatient physicians and pharmacists published in the Journal of Managed Care Pharmacy, only 16% of physicians reported feeling “very prepared” to discuss biosimilar choices with patients, and just 13% said they would switch a patient already stable on a biologic to a biosimilar.
There is a gap between formulary design and clinical behavior. Prescribers are not systematically informed when a biosimilar is available, clinically equivalent, and significantly less expensive for their patient’s plan. Without that signal, delivered clearly within the workflow they already use, most physicians continue writing what they know.
This is not a criticism of physicians. They are managing complex patient loads with fragmented information. The PBM sends utilization reports to the plan. The plan sends remittance data to finance. Nobody sends the prescriber a clear, actionable signal about cost and nobody has asked them to act on it. The system was not designed to close this loop. That is the problem.
What happens when the physician gets the signal.
RazorMetrics conducted a biosimilar campaign for a large health plan client. Within three months, the client saved $1.5 million.
That is the result from a single Basaglar-to-Semglee biosimilar exchange campaign run through RazorMetrics with a large national health plan. The savings were achieved without disruptions to the PBM, member experience, or clinician workflow. The campaign delivered a clinically grounded recommendation directly to prescribers inside their existing workflow, and physicians responded.
Across the full program, the same health plan generated $122 million in total savings combining therapeutic interchange, deprescribing, and biosimilar campaigns since program start. Members captured $24 million of that value directly in reduced costs.
The mechanism is straightforward in principle and operationally difficult without the right infrastructure. Identify members on a high-cost biologic for whom a biosimilar is clinically appropriate. Surface that information to the prescribing physician with clinical context. Make the recommended switch easy to act on inside the tools they already use. Then, track the outcome.
When that loop closes, savings materialize quickly. When it doesn’t close, the biosimilar sits on the formulary leaving the prescriber in the dark, and the plan pays brand prices indefinitely.
The barrier is not one thing. It is the whole system.
Physician hesitation is the most visible friction point, but it is not the only one. Biosimilar savings stall when any layer of the system fails to align, and in most plans, several layers are misaligned at once.
Formulary design is often the first gap. Analysis of over 950 self-funded employer plans found biosimilar cost variation of more than 4x for the same molecule, driven in part by how plans structure tiers, cost-sharing, and preferred placement. A biosimilar technically on formulary but sitting at a higher cost-share tier than the brand does not generate savings. It generates confusion. And yet plan sponsors continue to see cost variation that defies the availability of lower-priced options.
Member behavior could add another layer. Without physician-member communication, members unfamiliar with the biosimilar drug names may have questions at the pharmacy counter and delay fills. It is a predictable response to change without proper context.
And then there is the data visibility problem. Most plan sponsors can see what they spent. Far fewer can see, at the prescriber level, which physicians are driving biosimilar adoption and which are not, and why. Without that granularity, the plan cannot target the intervention, measure the result, or build on what is working.
The plans realizing the strongest biosimilar savings are not doing one thing well. They are closing the loop across all three layers at once: formulary placement that supports the switch, physician engagement that earns it, and member communication that completes it. That is not a formulary feature or a member app. It is a coordinated execution model.
What CFOs should be asking right now.
The biosimilar pipeline is the most significant near-term lever available to most plan sponsors for pharmacy cost reduction. Capturing it requires four things working in parallel:
- Preferred tier placement for the biosimilar at open enrollment, so it dispenses automatically without prior authorization when prescribed.
- Prescriber engagement that delivers biosimilar recommendations to physicians, not through member outreach programs that depend on patients navigating the switch themselves.
- Clinical credibility behind the recommendation. Prescribers respond to safety-grounded, physician-authored guidance. They do not respond to cost-optimization alerts that arrive without clinical context.
- Outcome tracking at the campaign level, because biosimilar savings that are not measured against a clear baseline are invisible in the claims data and impossible to attribute to the intervention.
Most analytics platforms can identify which members are on high-cost biologics with biosimilar equivalents available. Far fewer can close the loop by reaching the prescriber, earning the switch, and tracking the result in a format that holds up to finance-level scrutiny.
The savings are already in your population. The question is who captures them.
Every plan with specialty drug exposure has members on biologics that cost more than they need to. The biosimilar exists. The clinical evidence supports the switch. The savings are calculable before the program starts.
What determines whether those savings show up in claims is execution: whether the right physician gets the right recommendation at the right moment, and whether that recommendation is designed to be acted on rather than filed away.
With one campaign and one biosimilar change, RazorMetrics achieved $3 million in savings very quickly. We can do the same for you. Contact us today.
