COMPARISON OF DRUG AFFORDABILITY DECISIONS ACROSS STATE-LEVEL PRESCRIPTION DRUG AFFORDABILITY BOARDS AND THE CENTERS FOR MEDICARE AND MEDICAID SERVICES IN THE UNITED STATES
Author(s)
Julia Eustace, BSc1, Nicola K. Anderson, BA2, Shubhi Pathak, MPH2, Aashna Shah, MSc2, Aaditya Rawal, MSc2;
1Costello Medical, New York, NY, USA, 2Costello Medical, Boston, MA, USA
1Costello Medical, New York, NY, USA, 2Costello Medical, Boston, MA, USA
OBJECTIVES: To reduce prescription drug costs, state-level prescription drug affordability boards (PDABs) and the Centers for Medicare and Medicaid Services (CMS) have initiated affordability assessments and maximum fair price (MFP) negotiations, respectively. This analysis compared the PDAB and CMS processes and evaluations.
METHODS: PDAB-selected drugs and affordability assessments for states with published findings (Colorado, Maryland, Oregon) and CMS-selected drugs and negotiated discounts for 2026/2027 were reviewed, with data on key decision-making factors extracted from publicly available reports through January 2026.
RESULTS: PDABs have completed their reviews of most selected drugs (Colorado: 5/5, Maryland: 4/6, Oregon: 23/23). Colorado found 3/5 drugs “unaffordable”; Maryland concluded “affordability challenges” for 4/4. However, their reviewed drugs did not overlap. Colorado has set an upper payment limit (UPL) for 1/3 “unaffordable” drugs; Maryland recommended establishing UPLs for 2/4 drugs with “affordability challenges”, but none have been set to date. Oregon did not report explicit affordability conclusions and has no UPL authority. Of the 2026/2027 CMS-selected drugs, 9/25 were reviewed by ≥1 PDAB. PDABs drew affordability conclusions for 5/9 (all “unaffordable/affordability challenges”), with CMS discounts ranging from 66-71%. This list includes the drug for which Colorado adopted a UPL, with the CMS-negotiated MFP nearly equivalent to the UPL. While a ≥75% discount was negotiated for 6/25 CMS-selected drugs, 0/6 were reviewed by any PDAB. Key affordability considerations were similar across PDABs, emphasizing out-of-pocket (OOP) cost, wholesale acquisition cost (WAC), WAC changes versus inflation, drug accessibility, and therapeutic alternatives. CMS considerations overlapped but additionally focused on cost to other payers to ensure lowest possible MFP and costs recouped by manufacturers, while deprioritizing OOP cost and WAC.
CONCLUSIONS: While PDABs and CMS converge on several affordability drivers, differences remain. This, combined with limited detail in CMS reports, highlights the need for alignment and transparency around factors underlying drug affordability in these settings.
METHODS: PDAB-selected drugs and affordability assessments for states with published findings (Colorado, Maryland, Oregon) and CMS-selected drugs and negotiated discounts for 2026/2027 were reviewed, with data on key decision-making factors extracted from publicly available reports through January 2026.
RESULTS: PDABs have completed their reviews of most selected drugs (Colorado: 5/5, Maryland: 4/6, Oregon: 23/23). Colorado found 3/5 drugs “unaffordable”; Maryland concluded “affordability challenges” for 4/4. However, their reviewed drugs did not overlap. Colorado has set an upper payment limit (UPL) for 1/3 “unaffordable” drugs; Maryland recommended establishing UPLs for 2/4 drugs with “affordability challenges”, but none have been set to date. Oregon did not report explicit affordability conclusions and has no UPL authority. Of the 2026/2027 CMS-selected drugs, 9/25 were reviewed by ≥1 PDAB. PDABs drew affordability conclusions for 5/9 (all “unaffordable/affordability challenges”), with CMS discounts ranging from 66-71%. This list includes the drug for which Colorado adopted a UPL, with the CMS-negotiated MFP nearly equivalent to the UPL. While a ≥75% discount was negotiated for 6/25 CMS-selected drugs, 0/6 were reviewed by any PDAB. Key affordability considerations were similar across PDABs, emphasizing out-of-pocket (OOP) cost, wholesale acquisition cost (WAC), WAC changes versus inflation, drug accessibility, and therapeutic alternatives. CMS considerations overlapped but additionally focused on cost to other payers to ensure lowest possible MFP and costs recouped by manufacturers, while deprioritizing OOP cost and WAC.
CONCLUSIONS: While PDABs and CMS converge on several affordability drivers, differences remain. This, combined with limited detail in CMS reports, highlights the need for alignment and transparency around factors underlying drug affordability in these settings.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR95
Topic
Health Policy & Regulatory
Topic Subcategory
Insurance Systems & National Health Care, Pricing Policy & Schemes, Public Spending & National Health Expenditures, Reimbursement & Access Policy
Disease
No Additional Disease & Conditions/Specialized Treatment Areas