The EACH/PIC Coalition submitted comments to the Maryland PDAB on the proposed rule governing the implementation and monitoring of upper payment limits (UPLs) implemented by the board.
The letter stated:
“We urge the board to substantially improve the oversight and monitoring of upper payment limits; further, we urge the board implement patient protections prior to the implementation of any upper payment limit.”
“While we all share the goal of lowering patient costs for prescription drugs, we have long opposed upper payment limits because they remain untested, unproven, and risk creating new barriers between patients and their medically necessary treatments.”
“We urge you to ensure this experiment does not cause harm by including regulations or passing legislation to increase oversight and implement proactive patient protections before implementing a UPL in the state.
“Patients will bear the immediate consequences of insurer and PBM responses to UPLs, while any corrective action could take months or years. Monitoring the effects of a UPL after implementation cannot be a substitute for proactive protections.
Transparent Monitoring
“The PDAB must establish a robust monitoring system around any upper payment limit. The currently proposed monitoring system is inadequate to ensure patients are protected from increased utilization management and the potential for them to be non-medically switched. At a minimum, we propose that the following should be monitored for the entire therapeutic class where one or more drugs is subject to an upper payment limit:
- Collect and publish data from insurers and pharmacy benefit managers (PBMs) on formulary placement, tiering, utilization management, and cost-sharing changes for UPL drugs.
- Track provider-level impacts, including reimbursement rates, prescribing patterns, and patient access in physician offices, infusion centers, and pharmacies.
- Include independent evaluation to determine whether payer savings are being passed on to patients or retained by insurers and PBMs.
Legislative Guardrails
“At the same time, the board should work with the legislature to establish statutory protections to ensure UPLs do not create new barriers to care. Guardrails should include:
- Prohibiting non-medical switching of patients stabilized on a therapy.
- Banning new prior authorization or step therapy hurdles on UPL-affected drugs.
- Preventing adverse formulary shifts that push UPL drugs to higher tiers or exclude copay assistance.
- Protecting provider reimbursement so physicians, clinics, and pharmacies are not forced to absorb unsustainable financial losses.”