ADALIMUMAB BIOSIMILAR UPTAKE IN US MEDICAID: AN ANALYSIS OF MANAGED CARE VS. FEE-FOR-SERVICE EXPENDITURE TRENDS (2024-2025)
Author(s)
Christopher Daly, MBA, PharmD1, Jeromie Ballreich, MS, PhD2;
1Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, Baltimore, MD, USA, 2Johns Hopkins University, Wallingford, PA, USA
1Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, Baltimore, MD, USA, 2Johns Hopkins University, Wallingford, PA, USA
OBJECTIVES: To quantify the market shift from adalimumab (Humira) to biosimilars within US Medicaid Managed Care Organizations (MCO) and Fee-for-Service (FFS) programs following the 2024 commercial formulary expansion.
METHODS: We performed a retrospective analysis of CMS State Drug Utilization Data (SDUD) from Q1 2024 through Q2 2025. Adalimumab products were identified using National Drug Codes (NDCs) and categorized by manufacturer and biosimilars status. To ensure data integrity, duplicate dispensings were removed by restricting the analysis to national aggregate records (State "XX") and excluding individual state-level reporting. Given the heterogeneity in unit-of-measure reporting across manufacturers (e.g., - milligrams vs. kits), market share was calculated based on Total Amount Reimbursed (Expenditure Share) rather than raw unit volume. Trend were stratified by utilization type (MCO vs. FFS) to evaluate the impact of PBM-managed formularies versus state-administered lists. Data analysis was conducted using the Stata (v. 19.0) statistical package.
RESULTS: Analysis of 2024-2025 expenditure data reveals a distinct utilization pattern within Medicaid compared to the commercial sector. While Humira retained the majority of expenditure share (~57% in Q2 2025), the interchangeable biosimilar Cyltezo demonstrated substantial and sustained uptake within FFS programs, accounting for 28% of total adalimumab reimbursement. ($398M in Q2 2025). This contrasts with commercial trends where other biosimilars (e.g., Hyrimoz) typically lead. Other biosimilars, such as Amjevita (~10% share) and Hadlima (~2% share), showed moderate uptake, while Simlandi and Hyrimoz represented a negligible portion of Medicaid reimbursement during this period.
CONCLUSIONS: Medicaid biosimilar adoption is accelerating but follows a unique product selection trajectory distinct from major commercial PBM trends. The significant expenditure share of Cyltezo in FFS programs suggest successful state-level or Medicaid-specific contracting strategies that differ from the broader market. These findings highlight the importance of using expenditure-based metrics over volume-based metrics when analyzing Medicaid claims to avoid artifacts from unit-of-measure discrepancies.
METHODS: We performed a retrospective analysis of CMS State Drug Utilization Data (SDUD) from Q1 2024 through Q2 2025. Adalimumab products were identified using National Drug Codes (NDCs) and categorized by manufacturer and biosimilars status. To ensure data integrity, duplicate dispensings were removed by restricting the analysis to national aggregate records (State "XX") and excluding individual state-level reporting. Given the heterogeneity in unit-of-measure reporting across manufacturers (e.g., - milligrams vs. kits), market share was calculated based on Total Amount Reimbursed (Expenditure Share) rather than raw unit volume. Trend were stratified by utilization type (MCO vs. FFS) to evaluate the impact of PBM-managed formularies versus state-administered lists. Data analysis was conducted using the Stata (v. 19.0) statistical package.
RESULTS: Analysis of 2024-2025 expenditure data reveals a distinct utilization pattern within Medicaid compared to the commercial sector. While Humira retained the majority of expenditure share (~57% in Q2 2025), the interchangeable biosimilar Cyltezo demonstrated substantial and sustained uptake within FFS programs, accounting for 28% of total adalimumab reimbursement. ($398M in Q2 2025). This contrasts with commercial trends where other biosimilars (e.g., Hyrimoz) typically lead. Other biosimilars, such as Amjevita (~10% share) and Hadlima (~2% share), showed moderate uptake, while Simlandi and Hyrimoz represented a negligible portion of Medicaid reimbursement during this period.
CONCLUSIONS: Medicaid biosimilar adoption is accelerating but follows a unique product selection trajectory distinct from major commercial PBM trends. The significant expenditure share of Cyltezo in FFS programs suggest successful state-level or Medicaid-specific contracting strategies that differ from the broader market. These findings highlight the importance of using expenditure-based metrics over volume-based metrics when analyzing Medicaid claims to avoid artifacts from unit-of-measure discrepancies.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
EE400
Topic
Economic Evaluation
Topic Subcategory
Budget Impact Analysis
Disease
SDC: Systemic Disorders/Conditions (Anesthesia, Auto-Immune Disorders (n.e.c.), Hematological Disorders (non-oncologic), Pain)