Biosimilar Payer Restrictions Drop to 6 Percent

Employers should update benefit plan assumptions as 94% of policies now prioritize biosimilars over originator biologics.

Updated on Oct. 28, 2026 in Healthcare

Bold flat-color editorial illustration of two glass medical vials, symbolizing the shift in pharmaceutical payer policy. — Payer policy restrictions requiring originator biologics have fallen to 6 percent, marking a significant market shift toward lower-cost biosimilar alternatives. AI Illustration. Upload story photo >

Live Poll

Should insurance policies prioritize lower-cost biosimilars over originator biologics to improve patient health?

Payer policies in the United States have shifted significantly to prioritize biosimilars, with only 6% of policies now requiring patients to first fail an originator biologic. This decline from 55% in 2017 reflects a broader shift toward biosimilars as the preferred product to control treatment costs.

Why it matters

The rapid normalization of biosimilars in payer coverage reduces the barrier to entry for lower-cost alternatives, creating a more competitive landscape for biologic drug pricing. This alignment between financial policy and clinical adoption signals that biosimilars are now the default standard for cost-effective care.

Payer policies requiring patients to fail an originator biologic before accessing a biosimilar dropped to 6% in 2025, down from 55% in 2017. Currently, 94% of payer policies designate biosimilars as the preferred product.

The players

James Chambers

A researcher who presented data on the changing landscape of U.S. biosimilar adoption trends.

National Institute for Health and Care Excellence

The United Kingdom agency responsible for clinical guidance that previously rejected bevacizumab until biosimilar entry.

The details

Biosimilars function as cost-lowering mechanisms for biologic treatments by entering the market after originator patent expirations. Payers have accelerated adoption by removing restrictive 'step therapy' requirements that previously forced patients to try expensive originators first. This policy shift mirrors international regulatory precedents, such as the United Kingdom's experience where market entry for a biosimilar eventually enabled the approval of bevacizumab for metastatic colorectal cancer.

2017: 55% of payer policies required failure of an originator biologic.
2025: Only 6% of payer policies required failure of an originator biologic.
October 2026: James Chambers presented these findings at the AMCP Nexus 2026 meeting.

Market Landscape

The transition to biosimilar-first coverage follows the pattern set by the National Institute for Health and Care Excellence bevacizumab guidance, where market competition dictates access. This evolution mirrors the global trend of regulatory bodies adjusting standards once lower-cost alternatives become viable.

Business operators and benefit managers should expect fewer restrictive barriers for biosimilar coverage when evaluating employee health plans. The high rate of biosimilar preference now makes these products the standard baseline for pharmacy benefit negotiations.

The takeaway

The drastic reduction in step-therapy requirements confirms that biosimilars have shifted from an alternative to the primary market choice. Operators should track their pharmacy benefit utilization metrics to ensure their plans reflect this widespread shift toward lower-cost biosimilar products.