Unintended access barriers: How upper payment limit implementation may risk patient access.

Abstract

e23053 Background: Four states currently operate prescription drug affordability boards (PDABs) with purported authority to set Upper Payment Limits (UPLs; Colorado, Maryland, Minnesota, and Washington), while others are considering a range of state-level price setting mechanisms. These emerging policies, like the federal Inflation Reduction Act (IRA), introduce risks to patient access if, given existing incentives in plan coverage decisions, payers opt not to cover UPL drugs, place them on less favorable tiers, or apply utilization management (UM) to shift use to non-UPL drugs. To inform discussions around the potential risks of UPLs to patient access, we examined current coverage for policy-relevant oncology drugs in states with UPL authority. Methods: We analyzed pharmacy coverage, UM, and tiering, for the eight oral oncology drugs selected for or projected to be selected for the IRA’s Medicare Drug Price Negotiation Program. Using 2026 FingerTip Formulary data, beneficiary-weighted access was compared for included drugs between each PDAB state with UPL authority and aggregated access in the 46 other US states and District of Columbia (“non-UPL states”). We included health insurance exchange (HIX) and commercial plans, recognizing PDAB statutes vary in scope and may not apply to all ERISA-regulated self-funded plans. To conservatively represent access differences, differences of at least five percentage points were categorized as indicating “more” or “less” generous coverage, UM use, or preferred tiering. Results: Coverage for included drugs was generally similar in UPL and non-UPL states, apart from CO, where coverage was less generous for most drugs in HIX (n = 6/8) and commercial (n = 4/8) plans. Prior authorization (PA) barriers varied; compared to patients in non-UPL states, patients in CO and some in MD less often faced PA (CO commercial: n = 7/8 drugs; CO HIX: n = 6/8; MD HIX: n = 6/8), while commercially insured MN patients more often faced PA (n = 7/8). Step therapy was rare across drugs and states. Compared to patients in non-UPL states, those in three of four UPL states more often had access to included drugs on preferred tiers (HIX: MD, MN, WA; Commercial: CO, MD, MN). Conclusions: Patient access to oral oncology drugs in UPL states was often similar to – and sometimes better than – access in non-UPL states. These findings support concerns about future access waning through reduced coverage, adverse tiering, or increased UM, highlighting specific risks by state. For example, commercially- and HIX-insured patients in MD and MN more often have access to the included drugs on preferred tiers than those in non-UPL states; if UPLs were implemented, they may experience higher cost-sharing if plan sponsors placed the drugs on adverse tiers to steer patients towards non-UPL drugs. This research further informs discussion around meaningful PBM reforms that may improve patient access without UPL-associated risks.