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Findings Show Upper Payment Limits (UPLs) Could Increase Costs and Restrict Access to Critical Medicines March 31, 2025 (Washington, D.C.)  The Partnership to Fight Chronic Disease (PFCD) today released new research demonstrating that state Prescription Drug Affordability Boards (PDABs) and associated Upper Payment Limits (UPLs) may have unintended consequences that could negatively impact people living in with chronic diseases.  Interviews and a survey of health insurers confirm concerns many have raised: UPLs will likely increase patient costs and hinder access to prescribed medicines. These findings directly contradict assertions that state PDABs will improve affordability and access. A survey of regional and national health plan payers with PDAB-related experience and covering hundreds of millions of lives revealed significant concerns regarding the implementation of UPLs: 77% of health plan payers  believe UPLs would disrupt patient access to prescription drugs due to coverage changes, tiering adjustments, increased cost-sharing, or supply chain complications, including pharmacies potentially refusing to stock medicines with UPLs. 67% of payers  anticipate that patient cost-sharing for UPL-designated drugs will either increase (50%)  or remain the same (17%), while 70%  expect out-of-pocket (OOP) costs for drugs in the same class to either rise   (53%)  or stay unchanged (17%). 57% of payers  foresee increases in health insurance premiums if a UPL is enforced. 50% of surveyed payers  indicated that utilization management restrictions  on UPL-designated drugs would likely increase . 73% of respondents  expressed concerns that UPLs could lead to shortages  of critical medicines, with 60%  believing pharmacies might be unable to stock these drugs. 57% of payers  agreed that UPLs could result in providers receiving lower reimbursements for administering affected drugs, potentially reducing availability for patients. State lawmakers have introduced PDABs and UPLs in an effort to control health care costs and lower patient spending on prescription drugs. As of March 2025, eight states—Colorado, Maine, Maryland, Minnesota, New Hampshire, New Jersey, Oregon, and Washington—have enacted PDAB legislation, with four (Colorado, Maryland, Minnesota, and Washington) authorized to establish UPLs for drugs deemed “unaffordable.” However, definitions of “unaffordable” vary by state, and at least one PDAB has struggled to define this concept. While the intention behind PDABs and UPLs is to alleviate financial burdens on patients, the findings suggest that these policies may instead create significant disruptions, leading to higher patient OOP costs, premium increases, restricted pharmacy reimbursement, and reduced medicine availability. “People living with chronic diseases face constant challenges when it comes to managing their health, and prescription drug affordability boards are not a solution. Rather than improving affordability, UPLs could have the opposite effect—leading to increased costs for patients and limiting access to the medications they rely on to manage chronic conditions,” said Ken Thorpe, Chair of the Partnership to Fight Chronic Disease. “Policymakers should carefully consider the unintended consequences of these measures before implementing policies that may do more harm than good for the millions of people across the U.S. living with one or more chronic conditions.”  The full white paper can be viewed HERE .  An Avalere Insights piece can be viewed HERE .   ###

April 4, 2025 (Washington, D.C.)  – The Partnership to Fight Chronic Disease (PFCD) released the following statement in response to the announcement of the Contract Year (CY) 2026 MA and Part D final rule that will not include coverage of anti-obesity medications (AOMs). “There are many factors that contribute to America’s obesity epidemic. There are also many pathways to address it. Today’s decision blocks a major avenue for millions of Medicare and Medicaid patients who, without plan coverage, will not be able to access anti-obesity medications. “Patients and doctors deserve to have the latest scientific innovation on the table when making medical decisions. We are hopeful that, given the Trump administration’s mission to combat chronic disease, an alternative path will soon emerge, one that expands access to this important class of medications and eases obesity’s economic toll on our health care system.” For more information, please visit www.fightchronicdisease.org/obesity . ###