OBJECTIVES: Due to the rising cost of health care in the United States, payers have begun to place an increased emphasis on cost when evaluating new submissions for formulary access. Our objective was to evaluate the US payer perception of alternative pricing/risk-sharing (AP/RS) agreements focusing on: 1) assessing the success of previously implemented AP/RS agreements in the United States, and 2) evaluating conceptual AP/RS structures with payers to assess preference of concepts. METHODS: An online survey was conducted to evaluate the perceptions of a broad spectrum of US payers on AP/RS agreements (n=19). Following the survey, in-depth interviews (n=5) were conducted with US national and regional payers to gain additional insight. RESULTS:  More than 90% of US payers were interested in AP/RS agreements. Payers believed that these types of agreements could be implemented for both their pharmacy (84% of payers) and medical (42% of payers) benefits. Over half the payers (52%) believed that AP/RS agreements should be considered for orphan diseases, 68% believed that they should be considered for other rare diseases, and 73% believed that they should be considered for chronic high-prevalence diseases. Payers expressed concerns that previous AP/RS agreements were not successful due to a lack of independent data reporting and an imbalance in risk-sharing. Payers (73%) showed a preference for “pay-for-performance” schemes that offered predictable cost outlays and mutually beneficial risk agreements with clearly-defined and independently-verified success markers. CONCLUSIONS: US payers are keenly aware of alternative pricing/risk-sharing agreements and foresee them playing a larger role in future US negotiations if clear cost and risk benchmarks are established.