Health Plans Flag Patient Access and Cost Concerns as States Weigh Drug Price Caps

Avalere surveyed health plan executives on Prescription Drug Affordability Boards (PDABs) and upper payment limits (UPLs) now authorized in four states. Plans anticipate UPLs will force changes to formularies, cost-sharing, and pharmacy reimbursement, with 80% identifying patients as most impacted and most expecting increased out-of-pocket costs despite state affordability goals. While focused on commercial and state policy broadly, the findings have direct implications for Medicaid managed care plans operating in states with PDAB authority, particularly around pharmacy benefits and network adequacy.

Pharmacy · Managed Care

This is outside commentary from Avalere, not part of Medicaid Monitor's independently scored news coverage.

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