Economic feasibility of ‘Pay One Price’: an analysis of three biosimilar molecules with different prices and indicated for rheumatoid arthritis in a medium size HMO
Published on 18 May 2026
Generics and Biosimilars Initiative Journal (GaBI Journal). 2026;15(2).
Introduction/Objective: To evaluate the economic feasibility of a uniform ‘Pay One Price’ (POP) pricing model for three tumour necrosis factor (TNF) inhibitor biosimilars (adalimumab, infliximab, etanercept) used in rheumatoid arthritis (RA) treatment within a Brazilian medium-sized health maintenance organization (HMO). |
Introduction
Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects approximately 0.5% of the global population [1-3], with 25% of cases progressing to moderate or severe stages, requiring biological therapy for effective management [4]. The high cost of biological agents poses a significant challenge for healthcare systems, leading to disparities in treatment access and budget constraints.
Biological agents that are used in the treatment of RA include human monoclonal antibodies that treat autoimmune diseases by inhibiting tumour necrosis factor (TNF). These products bind to TNF-alpha (TNF-α), preventing it from activating TNF receptors, which cause the inflammatory reactions associated with autoimmune diseases such as RA, Crohn’s disease, psoriasis and ulcerative colitis. Examples of these include adalimumab, with originator product AbbVie’s Humira [5]; infliximab, with originator product Johnson & Johnson’s Remicade [6]; and etanercept, with originator product Amgen/Pfizer’s Enbrel [7].
The introduction of biosimilars has expanded treatment options for RA, offering the potential for cost savings while maintaining comparable efficacy and safety to originator biological products [8–10]. However, their adoption in clinical practice varies due to considerations regarding analytical similarity, immunogenicity, and clinician confidence [8, 10–11]. Understanding these dynamics is essential when evaluating pricing strategies aimed at optimizing biosimilar utilization within healthcare systems [11].
Objective
To evaluate the feasibility of Brazil’s ‘Pay One Price’ pricing model for biosimilars use in RA treatment, focusing on TNF inhibitors adalimumab, infliximab, and etanercept [12].
Methods
Medication prices were obtained from the Brazilian Chamber for the Regulation of the Medicines Market (CMED) [12] and expressed as per-dose acquisition costs in US dollars. Annual costs were subsequently derived by multiplying the per-dose cost by the recommended number of maintenance doses per year for each agent.
The analysis focused on three TNF inhibitor biosimilars: adalimumab, infliximab, and etanercept. Market utilization weights of 65%, 15%, and 20%, respectively, were applied based on global and regional market intelligence reports [13–16].
Rheumatoid arthritis prevalence was estimated at 0.5% of the global population [1-3], with approximately 25% of cases progressing to moderate or severe stages requiring biological therapy based on published epidemiological data. In Brazil, a cohort study of patients within the public health system (Sistema Único de Saúde, SUS) reported that biological agents represented a substantial proportion of RA treatment costs, highlighting the budgetary relevance of this patient population [17].
A hypothetical cohort of 100,000 covered lives within a medium-sized health maintenance organization (HMO) was considered, resulting in 125 patients eligible for biological treatment.
The economic evaluation adopted a one-year time horizon and included only drug acquisition costs, expressed as annual costs in USD, with no discounting applied due to the short-time horizon. Sensitivity analysis was not performed, as the objective was to evaluate the feasibility of the ‘Pay One Price’ pricing model under a deterministic scenario using observed market prices and utilization patterns. Parameter uncertainty was considered beyond the scope of this exploratory analysis.
Results
The annual cost for the three biosimilars, derived from per-dose prices and recommended maintenance regimens, were US$247.68 for adalimumab (3,000 doses/year), US$344.17 for infliximab (1,500 doses/year for a patient weighing ~70kg), and US$540.88 for etanercept (6,500 doses/year), as shown in Table 1.
To estimate a uniform per-dose price under the ‘Pay One Price’ (POP) pricing model, individual per-dose costs were weighted according to market utilization shares. This resulted in weighted per-dose contributions of US$160.99 for adalimumab, US$51.62 for infliximab, and US$108.17 for etanercept, yielding a POP price of US$320.78 per dose, as shown in Figure 1.
Figure 1: Cost per dose versus ‘Pay One Price’ model
When extrapolated to the eligible population, total annual expenditure under standard pricing amounted to US$157,898,469. Adoption of the POP model reduced annual spending to US$139,322,188, corresponding to an estimated annual budget saving of US$18,573,281, see Figure 2.
The comparative annual budget impact between pricing strategies of TNF inhibitor biosimilars is illustrated in Figure 2, with the annual cost comparison shown in Figure 3.
Figure 2: Cost savings comparison – standard pricing versus ‘Pay One Price’ model
Figure 3: Annual cost comparison – standard pricing vs ‘Pay One Price’ model (TNF inhibitor biosimilars)
Discussion/Limitations
The findings of this analysis should be interpreted within the context of several limitations. First, the analysis was based on a hypothetical cohort of 100,000 covered lives within a medium-sized HMO, which may not reflect the diversity of healthcare settings across Brazil, including FiSUS, which serves approximately 150 million individuals under different purchasing and reimbursement dynamics. Second, the market utilization weights (65%, 15%, and 20%) were derived from global and regional market intelligence reports and may not capture variations in prescribing patterns across different regions or healthcare plans [13-16]. Third, the analysis considered only drug acquisition costs and did not account for other relevant expenditures such as administration costs, monitoring, or adverse event management, which could affect the overall budget impact. Fourth, the one-year time horizon limits the ability to capture long-term cost offsets, such as reduced hospitalizations or disease progression averted with effective treatment. Finally, sensitivity analysis was not conducted, and therefore the robustness of the findings to variations in key parameters, e.g. RA prevalence, progression rate, dosing assumptions, was not assessed. Future studies incorporating probabilistic sensitivity analysis and longer time horizons would strengthen the generalizability of these findings.
Conclusion
Within the context of a medium-sized HMO in Brazil, the implementation of POP pricing model for biosimilars in RA treatment proved economically feasible. It reduces cost disparities between agents, optimizes overall healthcare spending, improves budget predictability, and ensures equitable access to effective therapies. Additionally, it supports better allocation of healthcare resources, benefiting both patients and healthcare systems. Further research is warranted to assess the model’s applicability across diverse healthcare settings and to evaluate long-term clinical and economic outcomes.
Acknowledgement
The authors wish to thank Dr Júnior M Alves from the Medical Sciences Faculty of UNICAMP (State University of Campinas), Brazil, for his valuable insights during the editorial review.
Funding sources
This paper was funded by Organon Brazil.
Declarations
This study was presented as a poster (ISPOR 2025 Code: EE244) at the ISPOR 2025 Annual International Conference, Montreal, Canada.
Competing interests: FEP and LPB declare no conflicts of interest. NU is an employee of Organon Brazil.
Provenance and peer review: Not commissioned; externally peer reviewed.
Authors
Professor Francisco Eduardo Prota1, MD, PhD
Ricardo Luiz Pereira Bueno2, BA, MHA, PhD
Nanci Utida3, MD
1Pontifical Catholic University of Campinas (PUCCAMP), Campinas, Brazil
2Graduate Program in Corporate Governance (MP-FMU), São Paulo, Brazil; Public Policy Program of School of Public Administration (DDPP-ENAP), São Paulo, Brazil
3Associate Director, Medical Affairs, Organon Brazil; Faculty of Public Heath USP, São Paulo, Brazil
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Author for correspondence: Professor Francisco Eduardo Prota, MD, PhD, Department of Gynaecology, Pontifícia Universidade Católica de Campinas (PUC-Campinas), Rua Professor Doutor Euryclides de Jesus Zerbini, 1516 – Parque Rural Fazenda Santa Cândida – Campinas – SP – CEP 13.087-571, Brazil |
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