Presentation (CTI)

OBJECTIVES: To understand US payer perspectives on the impact of federal price-setting policies, such as the Inflation Reduction Act (IRA), and potential US legislative reforms to pharmacy benefit managers (PBMs).
METHODS: Experienced stakeholders from US commercial payer organizations participated in an online survey in March 2025, consisting of 53 questions. Descriptive statistics and contextual analyses were conducted.
RESULTS: The survey included 18 participants, including 4 medical directors, 11 pharmacy directors, and 3 industry/trade relations representing national and regional managed care organizations, PBMs, and integrated delivery networks. Participants expected the IRA to have an impact (low: 39%; moderate: 33%; high: 28%) on biopharmaceutical innovation. When asked about the impact of the Medicare Drug Price Negotiation Program’s (DPNP’s) Maximum Fair Prices (MFPs) on access in commercial health plans, participants felt that there would be a moderate increase in restrictions (33%), little to no change in access (28%), and moderately fewer access restrictions (22%). Participants (50%) did expect some problems, but minimal negative impact on patient access due to MFP implementation. They expected a moderate-high likelihood (50%) of substantial federal reforms to the PBM market in 2025, with the view that PBMs would need to pass a greater percentage of rebates back to plan sponsors (36%) and would not be able to preferentially steer prescription to affiliated pharmacies (32%).
CONCLUSIONS: Overall, over 60% of US payers expected the DPNP to have a moderate to high impact on new drug innovation. However, only a third of participants thought that the DPNP would increase restrictions on patient access. Payers also thought that there was a chance of substantial PBM reforms in 2025. With a rapidly evolving healthcare policy and value assessment landscape in the US, it is critical to understand how these changing dynamics may impact payer access determinations to biopharmaceutical innovations.