Formulary design that captures the savings (without disruption)

  • 2 Min read

  • December 1, 2025

Susan Thomas

Susan Thomas

Chief Commercial Officer, LucyRx
Best Practices
doctor handing patient a prescription

Every decision on a plan shows up as someone’s refill, someone’s first injection, someone’s relief. That’s why our approach starts with people and lets the savings follow. In plain terms: A formulary line doesn’t lower costs by itself. People do when the plan is clear, the switch is simple, and support is built in. Care comes first; cost follows.

What this means for you

  • Lower net cost, same care. Biosimilars are held to the same safety and effectiveness standard as the brands.1 Your job isn’t to take on risk; it’s to choose the option that costs less and feels the same to your people.
  • Make the right choice the easy choice. If the lowest-net-cost option is effortless at the pharmacy and the doctor’s office, adoption follows.
  • Support matters. When members feel guided, not pushed, changes land well and therapy stays on track.

The simple plan (four moves)

  1. Choose the clinically appropriate, lower-cost option first.
    Don’t chase the biggest rebate. Choose the therapy that truly costs less after everything is accounted for. It’s better for the plan and fairer to your people.
  2. Align cost-share to the true price so the right therapy is affordable.
    Coinsurance tied to list price can make lower-cost options look more expensive at the counter. Match cost-share to net price so the affordable option is also the obvious one.
  3. Allow pharmacy substitution where it’s permitted.
    Some biosimilars can be substituted at the pharmacy (state rules apply)1. Set a simple, written policy and explain it in plain language.
  4. Put guardrails around the workflow
    Watch new prescriptions, follow up quickly with the prescriber when something doesn’t match plan intent, and give members simple support: how to use the device, when refills arrive, and who to call with questions.

What good looks like in practice

When employers follow this approach, biosimilars become the default at the start of therapy and the preferred switch for people who are stable on treatment, without disruption.

In our modeled scenarios for inflammatory conditions, that has looked like 85%+ biosimilar use and about $11 PMPM in net savings, with member experience remaining stable. (Modeled results; your plan will vary.)2

How we’ll help

We provide the guardrails for you: real-time monitoring, one-to-one prescriber outreach, and Care Guides for members so adoption rises and experience stays steady.

  • A one-sentence policy you can drop into your plan docs:
    “When clinically appropriate, the plan prefers the lowest-net-cost biosimilar, and member cost share is aligned to net price.”
  • A clear substitution summary (what’s allowed in your state, who to call)
  • Member-first communications your HR team can send as-is
  • A quarterly scorecard you can share with finance: adoption %, PMPM impact, member out-of-pocket, prescriber patterns, and appeals

The takeaway

Rebates look good on paper. Net savings feel good in real life—for your CFO and for your people. Keep it simple: lowest net cost, clear substitution rules, and human support.

Ask us for a biosimilar formulary review. We’ll show you where to start and stand up the member support to make it work. We measure success as better outcomes, clear experience, and lower net cost—in that order.

Request a Biosimilar Savings Review for Your Plan.

Our clinical and analytics teams will walk you through your potential savings and the member impact, step by step.

Contact us
Sources
[1] U.S. Food & Drug Administration — 9 Things to Know About Biosimilars and Interchangeable Biosimilars
[2] LucyRx analysis — Modeled scenario for inflammatory conditions

Tags

Biosimilars formulary design for savings Reducing specialty drug costs

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