Presentation (CTI)

OBJECTIVES: To assess U.S. payer perceptions of emerging federal drug pricing mechanisms and evaluate how the Inflation Reduction Act (IRA) and Most-Favored-Nation (MFN) pricing are expected to influence formulary coverage and contracting behavior across managed Medicare and Medicaid.​​
METHODS: Qualitative thematic analysis of structured interviews and advisory discussions with U.S. commercial, Medicare, and Medicaid payer decision-makers. Analyses focused on perceived economic impact, operational feasibility, and implications for formulary coverage, utilization management (UM), and competitive dynamics.
RESULTS: Among federal pricing initiatives, the IRA is viewed as having the most immediate impact, particularly within managed Medicare. Payers report that IRA-negotiated prices materially influence formulary coverage and tier placement for negotiated products, signaling preferred positioning in Medicare Part D and reshaping intra-class competition. Despite this impact, decision-making remains anchored in relative net cost, operational simplicity, and plan-level flexibility. Broader utilization expansion or contracting changes are not anticipated near term. MFN pricing, including potential implementation through the GENEROUS Model, is broadly perceived as having limited near-term impact. Payers consistently describe a wait-and-see approach, citing uncertainty around implementation mechanics, rebate interactions, and policy durability. As a result, MFN is not expected to drive widespread or immediate formulary or UM changes. However, payers acknowledge that MFN implemented via GENEROUS could disproportionately affect select disease states. MFN may influence future net pricing expectations or conditional formulary positioning, though effects are expected to be localized rather than systemic. Within Medicaid, GENEROUS is viewed as a net-price lever within state-controlled frameworks rather than a mechanism for access expansion.
CONCLUSIONS: Payers interpret federal drug pricing reforms primarily through a net-cost and operational feasibility lens. The IRA is currently exerting the greatest impact, particularly on formulary coverage of negotiated drugs in managed Medicare, while MFN via GENEROUS model is expected to have limited, uneven effects concentrated in specific disease states.