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 condition.”
 
The full white paper can be viewed HERE.
 
An Avalere Insights piece can be viewed HERE.
 
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