Group Insurance, Skwire, Daniel D., 7th Edition - Ch. 7: Pharmacy Benefits in the United States

Use this thread to discuss ANYTHING and EVERYTHING related to this syllabus reading.
Some possible questions include:

  • How can this reading be tested?
  • I don’t understand a specific topic/formula - Can we discuss this?
  • This reading gives me nightmares. Can we talk through it a bit?

Good luck!

For anyone who works in pharmacy:

Are specialty drugs just a subset of brand drugs, and is it only the fact that they have lower utilization & higher cost that separates them from the rest of brand drugs? In other words, do they follow the same life cycle as a brand name drug (brand patent protection, generic exclusivity, etc.), or do generics not exist for specialty drugs?

Also, is the relationship between biologics/biosimilars similar to the generic/brand relationship?

I don’t work in pharmacy, I’m not even in the US (I’m in Canada) so you can take the following with a grain of salt.
From what I understand, specialty drugs are indeed a subset of brand name drugs. They could have a generic, or not. Brand name drugs that don’t have a generic equivalent are called single source brand drugs and those that do are multi source brand. So specialty is not another word of single source. It’s really the fact that they are expensive and have low utilization that separates them from other brand name drugs.

The prescription drug lifecycle applies to them as well in my opinion.

As for the relationship, I don’t get what you mean. Biosimilars are another version of a biologic drug created later, usually for a cheaper price, so in a sense, they are a “generic” for the biologic drug. The thing is that biologics are so complex and include living organisms, that you can’t recreate the exact same drug. Generics and Brand name drugs are identical on a molecular level. Biologics and biosimilars treat the same conditions but they are not identical on a molecular level.
I hope that answers your questions, let me know if you’d like to discuss it some more!

Yes, that is super helpful! And you pretty much nailed my biologic/biosimilar question.

I was mainly wondering if there would be any kind of patent/exclusivity period where biosimilars wouldn’t be allowed to compete. I imagine there are similar patent strategies for biologic drug manufacturers, but it seems like either way biosimilars would have a hard time competing with biologics as much as generics do with brand drugs. I should give biologics more credit for their complexity.

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Yes there is a patent exclusivity period IMO. It definitely is a challenge to have people switch from the biologic they were taking to a biosimilar. I know that in recent years, it has been an area of focus for Canadian group insurance plans beause there is a great potential for savings.