The EACH/PIC Coalition submitted a comment letter to the Maryland PDAB, providing input on the board’s consideration of implementing a UPL for Ozempic.
The letter stated:
“We appreciate the opportunity to comment on the board’s proposed upper payment limit (UPL) rulemaking for Ozempic. We urge the board not to move forward with the proposed UPL since it does not directly address patient needs and alternative policy solutions have not yet been fully considered or evaluated by the board.”
“We continue to underscore the limitations of a UPL in addressing patient affordability. UPLs may change what insurers or the state pay for a medication, but they do not cap or guarantee reductions in patient out-of-pocket costs. As our coalition has cautioned before, these policies can introduce new incentives for insurers and pharmacy benefit managers (PBMs) that may ultimately restrict access to needed treatments through greater utilization management, formulary reshuffling, or adverse tiering. These shifts risk delaying or disrupting care, and as our Patient Experience Study has demonstrated, insurance barriers, not price alone, are often the real drivers of patient hardship and perceived ‘unaffordability.'”
“Maryland’s proposal to apply the “maximum fair price” (MFP) established by the Medicare Drug Price Negotiation Program (MDPNP) to state programs is concerning because those prices were negotiated specifically for the Medicare population and benefit design. Those rates reflect the structure and cost-sharing rules of Medicare, which are not the same as those that apply in state-regulated coverage. Applying those prices outside of Medicare assumes the markets function the same way, and they do not.”
“We have long cautioned that UPLs are not a patient-centered solution and have urged the board to seek the authority to implement alternative reforms that will better address patient problems. We urge once again that the board ensures non-UPL policy alternatives are given equal weight alongside UPL proposals.”
“The board is moving forward with establishing UPLs. Meanwhile, alternative policy options that may better address the needs of Maryland patients are advancing more slowly because the board lacks the authority to pursue them directly. Whether by design or simply ease of authority, the board has now demonstrated that UPLs are its preferred mechanism for intervention.”
“Moving forward with implementing UPLs will place more value on lowering system costs than on addressing real patient needs. We therefore urge the board not to move forward with approval of the UPL for Ozempic until the alternative policy recommendations under consideration also move forward.”