The United States is a global leader in medical innovation. Unfortunately, due to perverse incentives that exist in our current health care system to block lower-cost drugs from the marketplace, patients have difficulty accessing and affording those life-saving treatments. Biosimilars, which are nearly identical, lower-cost alternatives to complex biologic drugs, have the potential to increase competition and provide those benefits, but not unless the marketplace reflects that potential.
The largest-selling prescription drug in history, Humira, is an excellent example of the opportunity and cost-savings that biosimilars represent. For 20 years, patients suffering from debilitating chronic diseases, such as Crohn’s disease or rheumatoid arthritis, had one primary treatment option when it came to this drug. That changed when biosimilars for this product hit the Medicare Part D market this year. For the first time in two decades, more affordable treatment options for patients suffering from these chronic conditions are available, and the cost savings for both patients and the health care system are significant. On average, biosimilars make it easier for patients to take their medication as directed, which could result in potential savings of up to $38.4 billion over five years.
While this is great progress, pharmaceutical treatments, even the affordable ones, are only as good as a patient’s ability to access it. Unfortunately, pharmacy benefit managers (PBMs), to line their own pockets, create barriers to accessing these lower-cost alternatives.
It is often difficult to understand that insurance coverage doesn’t always translate to access. This is particularly true with retail pharmacy drugs which need to be on a “formulary,” which is an insurer’s list of accessible drugs. If a drug is not on this list, it is ineligible for insurance coverage. PBMs have significant influence over which medicines are on the formulary. Unfortunately, instead of making decisions about what drugs are covered based on the best options for patients, PBMs often steer patients towards the drugs with the most lucrative rebate structures, even if the out-of-pocket cost is higher.
While PBMs say they support the inclusion and utilization of biosimilars to help save patients money, their actions say otherwise. There have been instances where some formularies require prior authorization or step edits to access these medications, even without a discernible difference in the treatment options. There are also scenarios where higher-cost products are more readily available to patients, while lower-cost biosimilars are restricted, limiting access and savings for the patient. This harms the public’s confidence around these products and clouds the public’s perspective when they’ve been proven safe through years of utilization abroad.
While the problem is complex, the solution is not. We must increase formulary access for biosimilars. If PBMs commit to covering biosimilars, with no strings attached, patients will see savings in out-of-pocket costs. Unfortunately, PBMs appear unwilling to put patients’ health before profits.
This is a landmark year for the launch of biosimilars and a tremendous opportunity to save patients money while reducing health care costs. The only thing standing in the way of that are PBMs and their influence over the prescription drug landscape. Now is the opportunity for PBMs to truly reduce out of pocket spending and take the steps to increase access to FDA approved biosimilars on national formularies and allow them to compete. In the end, competition is a win-win for the market and the patient.
Buddy Carter represents Georgia’s 1st District, a pharmacist by trade, is a member of the House Energy and Commerce Committee and GOP Doctors Caucus.
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