1. Lack of state laws for automatic substitution (like for small molecules) 2. Payers often exclude brand when generics approved (for small molecules) "strong patient and physician aversion to requiring patients stabilized with branded biologics to switch to biosimilars for cost-saving purposes." 3.
Third, and most important, rebate agreements between pharmaceutical companies, pharmacy benefit managers, and other payers create an incentive for payers to prefer more expensive branded biologics over biosimilars. Most pharmaceutical companies currently provide rebates to pharmacy benefit managers to support preferred position of their branded biologic drugs on payer formularies.
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