Access USA 2025: This Year’s State of the Industry

Image Credit: Nicholas Saraceno

Day 1 of Informa’s Access USA Conference from Philadelphia—featuring Patient Assistance & Access Programs (PAP) and Hub and Specialty Models East—was kicked off by Tommy Bramley, Cencora’s SVP of global consulting services.

Titled “State of the Industry—The Evolving Landscape of Healthcare Coverage and Access in 2025,”¹ the goal of the Access USA general session was explore the dynamics impacting healthcare coverage and access this year, with an emphasis on industry-defining issues.

Bramley led off the session with the thought-provoking question of what most concerns attendees in terms of maximizing patient outcomes. The audience felt that the following:

• Right therapy: 47%
• Right time: 37%
• Right patient: 16%

After establishing where stakeholders’ priorities lie, he alluded to three main challenges that lie ahead concerning uncertainty: US federal and state policy priorities; unintended consequences of the Inflation Reduction Act (IRA); and payer economics.

US federal and state policy priorities

When it comes to pharmaceuticals, the current Trump administration’s priorities are still being developed. Little has been released from Project 2025 regarding pharmaceutical changes Bramley noted, but IRA negotiations for 2027 are continuing. Pharmacy benefit manager (PBM) legislation is also under discussion by Congress.

There are various initiatives that could possibly affect PAPs. Regarding Medicaid, there is an interest in reduced Medicaid spending by $2.3 trillion over 10 years, with the chance to lower Medicaid expansion funding. These—along with other factors—could decrease enrollment and place pressure on PAPs.

Back during the Biden administration, coverage was proposed for anti-obesity meds under Part D and Medicaid. If this were to be finalized, Medicare Part D and Medicaid beneficiaries would have GLP-1s covered, but the projected costs to both federal and state governments would be $15 billion. Just for additional perspective, obesity costs the United States $480 billion in direct costs, and $1.24 trillion in indirect costs.

“This starts to point out the challenges with our healthcare system and willingness to pay, versus ability to pay, and certainly our ability to deal with chronic diseases. So yes, we want to address these direct costs,” Bramley stated.

In order to address those indirect costs, there are currently 11 state prescription drug affordability boards that exist to control cost at local or state level.

IRA unintended consequences

Patients have expressed relief related to the $2000 out-of-pocket (OOP) cap, and come 2026, it’s believed that during the initial coverage phase, plans will cover 65% of coverage, followed by the patient at 25%, followed by either the manufacturer or government covering the remaining 10% over the plan year. In the catastrophic phase, the plan would cover 60%, manufacturer 20%, and either the government covering negotiated or applicable drugs at 40% or 20%.

Meanwhile, the IRA introduces the Medicare Prescription Plan (M3P), which allows one to spread OOP prescription drug costs over the course of a year as opposed to paying them all at once at the pharmacy. It’s currently a work in progress—being in its first year, there is no ability to enroll at point of sale at this moment. In the long-term however, Bramley explained that it could help improve Rx drug affordability, while increasing patient adherence. The intention is to achieve price smoothing, which involves stabilizing prices and reducing price fluctuations, often by averaging prices over time or across different periods.

Patients are also worried concerning changes to current Part D plans, such as premium increases or other restrictions. As it stands now, the future of standalone prescription drug plans is uncertain.

There are also concerns about access to next year’s negotiated products—although plans are required to cover negotiated drugs, there aren’t mandates regarding coverage methods.

Payer decisions driving access barriers

Last year, the Big 3 PBMs reportedly excluded 1,453 unique Rx medicines from their formularies, representing a 1,233 rise from 2014. And from 2014-2025, the number of meds that were excluded by one or more PBMs rose by an average of 38% per year.

The problem lies with affordability. Even when a prescription is filled, 90% of Rxs cost under $20, but 1% cost more than $125. For about one-third of brand-name commercial prescriptions across the top 10 therapy areas and for 63% of obesity Rxs, patients use copay cards.

For the aforementioned 1% of higher costs, this is where copay accumulators, copay maximizers, and alternative funding programs come into play, which will be explored more in-depth throughout the conference.

Reference

1. Bramley T. State of the Industry—The Evolving Landscape of Healthcare Coverage and Access in 2025. March 18, 2025. Access USA (general session). Philadelphia.