Why Create a Tool That Measures Access and Affordability of Price-Controlled Medicines?

As described, PBMs may need to make changes in the delivery and pricing of the Part D benefit to maintain their current level of profitability.  However, for political reasons, PBMs might do nothing and maintain the current access to MFP drugs with the current OOP requirements for enrollees.  This strategy would likely draw less scrutiny from the Center for Medicare and Medicaid Services (CMS) and other health policymakers.

On the other hand, to mitigate the profit fallout of reduced rebate revenues for medicines with an MFP, PBMs could increase patients’ OOP costs for those medicines. Such increases could be achieved by placing a medicine on a higher tier within a formulary or by raising OOP without changing the tier due to the wide range of co-pays that exist within tiers. PBMs might also attempt to control costs by imposing more administrative burdens that reduce medication access. However, such a scheme might be riskier as it would likely draw CMS’s attention.

We do not know which strategy PBMs will adopt, so we decided to create a transparent tool utilizing publicly available data from the CMS and proprietary data acquired from IQVIA that will display fluctuations in OOP costs for MFP drugs and changes in administrative burdens and tier coverage of MFP drugs.  The data, we believe, will speak for itself.