Op-Ed: Expand Patient Choice to Lower Medication Costs

Prices are on the rise nationwide, from food and gas to utilities and medications. Nowhere is the need for transparency in pricing more apparent than in our convoluted drug pricing system, where business practices can impact individuals’ health. Much has been written about this complex supply chain and the many factors impacting how much the end patient ultimately pays.

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Thankfully, biosimilars are a cost-effective alternative for patients battling complex and chronic diseases to benefit from innovations in biologic treatments. But, as I recently testified to Congress,¹ policymakers can do more to help expand access to and lower costs for innovative biosimilars.

So, what are biosimilars, and what are some of the barriers to accessing these medications?

First, it is important to understand the differences between biosimilars and biologics. Biologic drugs have been widely used since the late 1990s, revolutionizing the treatment of various chronic health conditions, including rheumatologic diseases and cancer. While they are more effective in addressing complex diseases than synthetic drugs, biologics are also much more complicated and expensive to produce, and their administration to patients is more intricate since they must be given by injection or infusion.

Biosimilar drugs, meanwhile, are cost-saving alternatives to biologics. At the regulatory level, at least, the relationship between biologics and biosimilars is similar to that of brand-name medications and generics.

And while some biosimilars have been available for nearly a decade, we’ve seen limited availability and slow uptake despite Congress giving the FDA 2 pathways to authorize biosimilars while ensuring their effectiveness and protecting patient safety. With their proven health and cost-saving benefits, why aren’t more physicians and their patients using biosimilars?

The delay is largely due to opaque and deeply flawed reimbursement policies combined with the deceptive, profit-driven practices of insurers and pharmacy benefit managers (PBMs) which prevent patient savings from materializing.

The American College of Rheumatology and independent rheumatology practices, including my own, have been working to address the lack of adequate reimbursement for biosimilars for years. Whether the patient is covered by Medicare Part D’s complicated cost-sharing structure that forces physicians to lose money administering biosimilars or underpayments from PBMs who retain negotiated rebates, the growing gap between the cost of acquiring and administering biosimilars and the lesser amount we are reimbursed after treating a patient with them is weakening physician practices and impacting access to care for millions of patients suffering from chronic disease nationwide.

Initially, biosimilars are around 15% to 35% less expensive than their reference drugs,² which should translate to out-of-pocket savings for patients who switch to biosimilars from biologic therapies, with no decrease in the quality or efficacy of their medication. However, if a biosimilar is covered under Part D, then different cost-sharing rules often apply that negate any savings. This is especially true for patients in the coverage gap phase, when beneficiaries are responsible for a larger portion of the medication cost.

According to a 2018 study, 96% of Part D plans covered infliximab (Remicade; Johnson & Johnson), a biologic used to treat rheumatoid arthritis, Crohn disease, and a range of other autoimmune diseases. However, only 10% of those plans covered infliximab-dyyb (Zymfentra; Celltrion), the biosimilar version of the medication.³ Because all plans required coinsurance cost-sharing for biosimilars with copay rates similar to their biologic counterparts, the projected cost to the patient was actually higher for infliximab-dyyb, despite this biosimilar having a cheaper list price than its biologic reference product.

Meanwhile, reimbursements below the cost of acquisition to providers also continue to stifle the broader use of biosimilars. PBMs often negotiate rebates with drug manufacturers in exchange for placing a specific biologic or biosimilar on their formulary, a curated list of medications covered by a health insurance plan. This rebate will bring down a drug’s average sales price (ASP) as the current ASP definition factors them in. ASP is typically the basis for physician reimbursements for in-office treatments but does not influence the cost to the practice to acquire the medication. This process creates a perverse situation where the medication costs more than what physicians are being reimbursed, while PBMs can pocket the difference in profits. There are three proposals to fix current biosimilar challenges detailed in my recent congressional testimony,¹ that if implemented would increase patient access to these treatments.

This is especially harmful to smaller, independent, and rural rheumatology practices that cannot afford to operate at a loss if they choose to prescribe and administer biosimilars. While larger hospital groups and health systems may have the resources to absorb these financial losses, smaller practices operating on already shrinking margins cannot. And after years of inflation, rising medical costs, and cuts to Medicare physician payments, many smaller practices are already being pushed to the brink of closure, if not past it.

Despite some lawmakers in Congress attributing the slow uptake of biosimilars to distrust among doctors and patients, the truth is that the lack of transparency in drug pricing and the profit-driven PBM rebate system are distorting the marketplace and preventing patients from benefiting from the cost savings that these innovative treatments could provide. It is time for Congress and the administration to work together to increase transparency in drug pricing and help create a more equitable marketplace for providers and patients nationwide.

REFERENCES

1. Edgerton C. Testimony of Dr. Colin Edgerton, MD. Presented to the United States House of Representatives Committee on Ways and Means, Subcommittee on Health; April 8, 2025. Accessed June 2, 2025. https://waysandmeans.house.gov/wp-content/uploads/2025/04/Edgerton-Testimony-1.pdf

2. Feng K, Russo M, Maini L, Kesselheim AS, Rome BN. Patient out-of-pocket costs for biologic drugs after biosimilar competition. JAMA Health Forum. 2024;5(3). doi:10.1001/jamahealthforum.2023.5429

3. Yazdany J, Lin GA, Kim SC, et al. Out-of-pocket costs for infliximab and its biosimilar for rheumatoid arthritis in Medicare. JAMA. 2018;320(9):969–970. doi:10.1001/jama.2018.12383