had hearings on off-patent drugs with limited or no competition. in 2017, democratic party leaders announced a plan to enforce limits on how much pharmaceutical companies could raise drug prices. under the plan, drugs with a "significant price increase" would have to explain the price rise to the hhs a minimum of 30 days before implementing the price hike. although turing pharmaceuticals' daraprim price rise of 5000% overnight would meet the proposal's definition of a "significant price increase," under the proposed plan, mylan's well-publicized price increase for epipen would fall below the thresholds in the plan's criteria for enforcement. new legislation on october 9, 2017, governor jerry brown of california passed senate bill 17 (sb-17) health care: prescription drug costs. this bill focuses on transparency regarding pharmaceutical companies. this bill mainly focuses on two aspects. the first being that drug companies must give prior notice of price increases for prescription drugs. drug manufacturers must notify state purchasers such as calpers, medi-cal etc. 90 days prior to the planned effective date. the second focus is on the transparency of spending trends. this means that health plans and insurers have to annually report the following for all covered drugs (categorized by generic drugs, brand names, and specialty drugs): the 25 most prescribed drugs the 25 most costly drugs the 25 drugs with the highest year-over-year increase in total annual spending. this information was intended to help the public and policy makers see and understand pharmaceutical spending trends. canada's model in canada, the patented medicine prices review board (pmprb) determines a maximum price for all drugs. in 1987, bill c-22 established an extended period of protection for patents prior to licensing, which would allow for generics to enter the market. it also created the pmprb, an independent semi-judicial body, which had the purpose of establishing review guidelines of individual drug prices, conduct investigations for allegations of excessive pricing, and negotiations to a voluntary compliance agreement. these efforts are to ensure that manufacturer prices are within justification, and not excessive. excessive is interpreted based on the following criteria: the price of an existing patented drug cannot increase by more than the consumer price index (cpi) the price of a new drug (in most cases) is limited so that the cost of therapy with the new drug is in the range of the costs of therapy with existing drugs in the same therapeutic class. the price of a breakthrough drug is limited to the median of its prices in france, germany, italy, sweden, switzerland, britain, and the united states. in addition, no patented drug can be priced above the highest price in this group of countries. low levels of drug spending in canada are not solely attributable to the regulatory activities of the government, but also the actions of provincial and private insurance plans. these plans prevents price inflation through formulary management, independent clinical review of new products, reference-based pricing, the lca, and limited use program. in reviewing formularies, the drug program reviews the therapeutic advantage of one product over the existing formulary, and only adds new drugs if program costs are unchanged. the reference-based pricing entails having a "reference product" for each category that is the baseline price, and utilizes an independent panel of pharmacists and doctors the university of british columbia to evaluate the therapeutic discrepancies between drugs. the lca, or low-cost alternative program establishes the price of generics for payment regardless if brand or genetics are used. the limited use program requires prior authorization for specific drugs, and restricts reimbursements to the approved rationale of prior authorizations (i.e. patients who have failed previous agents for the same indication). the government is purchasing drugs similar to how the united states purchases medications for military personnel, but on a much wider scale.: 280 gail wilensky, former director of medicare and medicaid, said that because most other countries' governments set prices and the u.s. does not, the united states is effectively subsidizing drug development for other countries. she believes if the united states started setting prices, it would disproportionately impact new drug development. she predicted that the tradeoff if prices were set too low, would be fewer new treatments coming to market in about a decade (due to the long development lifecycle). david mitchell of the advocacy group patients for affordable drugs argues that in the face of reduced pharmaceutical company profits, government-funded research could provide an ongoing pipeline of new treatments. healthcare providers healthcare providers can help lower drug prices by helping patients navigate the medication formulary, prescribing drugs covered by formularies, and participating in formulary development through pharmacy and therapeutics committees. the formulary system's effectiveness is directly correlated to the education of physicians, pharmacists and patients in understanding the justification of formulary compositions. this education includes drug information monographs to provide adequate resources to physicians in making clinical prescribing decisions, pharmacy education regarding any changes in the formulary, and patient education within the managed care system. formularies should be easily accessible for patient access as well, such as the online medicare planfinder, which is part of the medicare part d plan. healthcare providers can substitute three-month for one-month supplies of medicines. a three-month supply represented a 29% decrease in out-of-pocket costs and an 18% decrease in total prescription costs in one study. prescribing combination drugs instead of two separate medications can also potentially reduce monthly copays. because the fda has no regulations on drug companies in providing evidence that a new drug has a therapeutic advantage over an older drug, many physicians have a tendency to write prescriptions for drugs they are most familiar with. oftentimes, these prescribing practices are influenced by manufacturer marketing to private practices or hospitals. prescriber monitoring programs should be implemented to help physicians make cost-effective, evidence-based prescribing decisions, and foundation protocols should be established. this is important to ensure that the most clinically-effective drugs are selected, and if a more expensive drug is selected, that appropriate therapeutic equivalence is evaluated with research supporting this decision. however, some organizations believe that if the federal government modified reimportation laws, the fda could conduct a comprehensive assessment on manufacturing standards in other countries, and allow importation of drugs that meet or exceed u.s. safety standards for drug manufacturing. individual importation of lower cost prescription drugs from foreign countries – as done by 2% of u.s. consumers in 2011 and 2012 – is likely not an effective public health solution. however, if the federal government modified reimportation laws, the fda could conduct a comprehensive assessment on manufacturing standards in other countries, and allow importation of drugs that meet or exceed u.s. safety standards for drug manufacturing. medicare for all h.r.3, elijah e. cummings lower drug costs now act, is a 2019 house of representatives approved bill that would allow the secretary of health and human services (hss) to negotiate with pharmaceutical companies for some of the most expensive drugs covered by medicare part d. this negotiation would manifest as a price ceiling, ensuring the medicare part d would pay no more than the negotiated price for the expensive drugs. this proposal received support from president biden during his campaign. bernie sanders' 2019 medicare for all proposal expands upon this bill proposal by requiring a universal health care system instead of private insurance. with this universal health care system, the negotiation style from h.r.3 would apply to everyone under medicare for all, rather than just the current recipients of medicare. price controls on the pharmaceutical industry have some empirical evidence to support the policy. the united states’ international trade administration reports the oecd companies with price controls drug prices range from 18 to 67 percent lower than the us’s, depending on the drug. there are several reasons why some experts believe that price controls on the pharmaceutical industry have some serious downsides. the national bureau of economic research conducted a study in 2014 that found that price regulations significantly delayed the launch of new drugs. moreover, a study done by dr. david stewart found that 260 life-years are lost per hour of delay for drug approval. sanders’ proposal may mitigate delays with the inclusion of an inability to negotiate section, which states if the negotiation is unable to conclude, the hss may price the drug at no more than the amount of one of three different prices. these prices include the price the secretary of veterans affairs pays, the price of the drug under section 8126 of title 38, united states code, and the price paid under a section of social security.