Verified-RX Podcast
Don't set it and forget it: Managing biosimilar formulary dynamically
Strategic biosimilar optimization can help health systems evaluate medication choices through a broader clinical, operational, financial, and payer-focused lens. Dr. Jerry Rebo from Novant Health joins host Heather Pace to discuss a structured quarterly process for reviewing biosimilar performance, monitoring payer preferences, identifying denial trends, and supporting informed therapy decisions. He shares practical guidance for health systems, building a similar approach with existing resources.
Guest:
Jerry Rebo, PharmD, MBA, BCPS, BCCCPS, D-PLA
Director of Value & Outcomes
Novant Health
Host:
Heather Pace, PharmD
Senior Clinical Manager, Ambulatory
Center for Pharmacy Practice Excellence, Clinical Spend Management
Vizient
Show Notes:
[00:55]
- The challenges of managing biosimilars across clinical care, clinic operations, reimbursement, payer contracting, prior authorization, and patient experience.
- The factors Novant Health considers when evaluating biosimilar products and therapeutic classes.
[01:51]
- Novant Health’s structured four-week review process, beginning with data collection from studies, reimbursement reports, payer policies, denial trends, and margin analysis.
- The role of therapeutic class reviews, clinical feedback, operational considerations, and financial performance in developing quarterly recommendations.
[03:27]
- The purpose of a biosimilar payer table and the way it tracks formulary updates, payer preferences, documentation requirements, and denial trends.
- How payer information supports communication among medical teams, authorization teams, pharmacy teams, and informatics partners.
[04:52]
- The difference between responding to individual denials and monitoring denial patterns over time.
- The value of identifying whether denials are connected to internal operational issues or changes in payer policies and plans.
[06:49]
- How expected payment rates are calculated by comparing actual reimbursement with billed amounts.
- The importance of reviewing reimbursement performance regularly so product recommendations can be updated as conditions change.
[07:56]
- The challenges of identifying opportunities for optimization across different therapeutic classes and payer types.
- Why Medicare Advantage plans require additional review since their preferences may differ from standard Medicare formularies.
[09:36]
- The value of breaking down organizational silos and bringing pharmacy, revenue cycle, clinical, operational, and administrative experts together.
- How a systematic biosimilar review process may support future medication management efforts involving biologics, cell therapies, and gene therapies.
[10:53]
- Practical advice for health systems that want to begin a biosimilar optimization process with limited resources or staffing.
- The importance of connecting with colleagues, learning from related initiatives, and mapping existing workflows before building a new process.
[12:02]
- Opportunities to use automation and technology to reduce manual data preparation.
- The potential for more efficient tools to give teams additional time for analysis, recommendations, and implementation.
[13:16]
- The importance of building relationships across the health system to solve shared problems.
- The role of cross-functional collaboration in supporting successful biosimilar management.
Links and Resources:
Vizient 2026 Connections Summit (poster presentations will be available for viewing on Oct 7)
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