As the 119th Congress convenes, policymakers have a historic opportunity to lower prescription drug prices for Americans. As members of Congress begin negotiating the continuing resolution set for March, they can make prescriptions more affordable for Americans and eliminate government waste in the American health care system by prioritizing pharmacy benefit manager (PBM) reform.
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PBM reform did not make it into the final continuing resolution this past December. Now, time is of the essence for it to pass. In addition to helping Americans access the medicines they need, savings from biosimilars are critical to cutting costs in government health care programs and eliminating wasteful government spending.
The PBM system intentionally blocks lower-cost, FDA-approved biosimilars from being available to patients. Biosimilars are the commonsense, bipartisan solution to out-of-control prescription drug prices.
Biosimilars are FDA-approved medications and on average more than 50 percent lower-cost versions of biologics that treat cancer, diabetes, psoriasis, arthritis, eye disease, and many more conditions. Brand biologic medicines are some of the most expensive drugs in the world. Despite being just 4 percent of total prescriptions, they represent an astounding 40 percent of total prescription drug spending. There are 10 biosimilars for Humira, the world’s best-selling drug that can cost up to $84,000 annually. These biosimilars on the market today are 85 percent lower cost than the brand drug, yet PBMs are blocking patient access to these lower cost biosimilars.
In the last 10 years, biosimilars have been associated with savings of $56 billion compared to what spending would have been without biosimilars. The next five years could result in an increase in savings up to $181 billion as newly approved biosimilars launch and existing biosimilars see continued uptake and price reductions. These cost-savings can be critical to providing access and coverage for millions of Americans for new innovations, such as GLP-1s and new treatments for conditions like cancer.
However, PBMs have blocked—and continue to block—this promise of biosimilars because they prioritize their own profits over the well-being of patients. This is unacceptable and must be rectified in a comprehensive PBM reform package.
Bipartisan investigations and studies highlight this problem. As Congressman James Comer (R-Ky.) and the House Oversight Committee found, the PBM monopoly is behaving in dangerous and anti-competitive ways at the expense of American patients. The three major PBMs control 80 percent of the prescription drug marketplace and actually profit from providing higher-priced prescription drugs to patients—leading to the exclusion of lower-cost, FDA-approved biosimilars for patients in need. In addition to House Oversight, the bipartisan leadership of the Senate Finance Committee and federal regulators at the Federal Trade Commission (FTC) launched their own probes of PBMs—all finding that PBMs operate in ways that hurt patients.
Congress must build on the reforms drafted in 2024 that require PBM transparency, delink the PBM monopoly’s business practices from the Medicare program, and allow all patients to have access to lower-cost medicines like biosimilars. A robust reform package can even save the U.S. billions of dollars from biosimilars through the end of next year and bring forward fiscal responsibility in health care.
The time to act is now. The 119th Congress can easily begin cementing its health care legacy through immediately pushing forward policies that are a win for patients. Patients simply cannot continue to bear the brunt of an exploitative PBM system that burdens them with unaffordable prices for life-saving medications.
Juliana Reed is executive director and co-founder of the not-for-profit U.S. Biosimilars Forum, which advocates for policy changes around biosimilar medications.
The views expressed in this article are the writer’s own.
