Biosimilar Tier Placement: How It Affects Your Medication Costs and Access

When you hear biosimilar tier placement, the system pharmacies and insurers use to decide how much you pay for biosimilar drugs compared to brand-name biologics. Also known as formulary tiering, it directly controls whether you pay $10, $50, or $300 a month for the same medicine. This isn’t just paperwork—it’s your wallet, your health, and your access to treatment.

Pharmacy benefit managers, companies that negotiate drug prices and set coverage rules for insurers. Also known as PBMs, they decide where biosimilars sit on the formulary ladder. Most put them in Tier 2 or 3—lower than brand-name biologics (Tier 3 or 4) but higher than regular generics (Tier 1). That means you pay more for a biosimilar than you would for, say, metformin, even though it’s just as safe and effective. Why? Because PBMs often get kickbacks from brand-name makers to keep their drugs on top. You don’t see the money trail, but you feel the price tag.

Formulary tiers, the levels insurers use to group drugs by cost and coverage. Also known as drug tiers, they’re not based on science—they’re based on profit. A biosimilar might be 30% cheaper than the brand, but if your plan puts it in Tier 3, you still pay 40% of the cost. Meanwhile, the brand stays in Tier 4, and your copay barely changes. That’s not a mistake. It’s a business model. And it’s why millions of patients with rheumatoid arthritis, Crohn’s, or diabetes are stuck paying more than they should for biosimilars that could save them hundreds a month.

Some plans are starting to fix this. A few now put biosimilars in Tier 1—same as regular generics—with a $5 copay. Others require you to try the biosimilar before covering the brand. But too many still make it harder to get the cheaper option. You might need prior authorization, step therapy, or a letter from your doctor just to get a drug that’s already FDA-approved and proven safe.

What you can do? Know your plan. Check your formulary. Ask your pharmacist if there’s a biosimilar version of your drug and what tier it’s on. If it’s not in the lowest tier, ask your doctor to appeal. Many patients don’t realize they have a right to request a tier exception—and most get approved if they show the biosimilar is medically appropriate.

Below, you’ll find real-world guides on how drug pricing works, what to do when your medicine disappears from shelves, how to spot dangerous mix-ups, and how to talk to your provider about cheaper options. These aren’t theory pieces—they’re tools for people who need to pay less and get better care.