Article

PDABs: An imperfect solution to a complex issue

Elaine Tate, BSc

Acknowledgements:
Andrew York, Executive Director MD PDAB
Katie Chandra, Senior Director and Head of State Policy at Genentech
Tiffany Westrich-Robertson, CEO and founder of International Foundation for Autoimmune & Autoinflammatory Arthritis (AiArthritis), lead of Ensuring Access through Collaborative Health (EACH), and coordinator of Patient Inclusion Council (PIC)

An imperfect system of Prescription Drug Affordability Boards may deliver the promise of lower-cost medicines to patients, but is there room to improve?

The pricing of prescription drugs in the United States

Pricing for prescription drugs in the United States is complex and can be difficult to navigate for many patients. There is a perception that high prescription drug prices impair access for patients. High prices are blamed on manufacturers, pharmacy benefit managers, and insurance providers. To control prices, the federal government is undertaking price negotiations for those pharmaceuticals with the largest Medicare spend under the Inflation Reduction Act. Recently, President Trump signed an Executive Order outlining plans to obtain most-favored nation pricing for pharmaceutical products. Additionally, the Trump administration has proposed tariffs on imported pharmaceutical products and active pharmaceutical ingredients.

At the state level, some have enacted legislation to allow pharmaceutical imports from Canada, while 11 states have enacted legislation to form Prescription Drug Affordability Boards (PDABs).

An introduction to PDABs

PDABs are proposed as a mechanism to control spending on prescription medicines, which are deemed ‘unaffordable’ for patients and state purchasers. The first PDAB was introduced in 2019 by the Maryland legislature. The National Academy for State Health Policy outlined a process for PDABs as described in the diagram below.

However, within this framework, individual PDABs develop their own processes to identify and select the drugs that will be assessed, determine how the assessment is conducted, and decide how/if UPLs are set, within the legislation enacted in their state. It is this variation of practice that makes the PDAB process in the states unpredictable and unreproducible.

The goal: Allow access to the right drugs for patients who need them—it’s simple, right?

Maybe not quite so much! PDABs originated as a way to police drug price gouging. UPLs were established to cap costs, but the evidence suggests that any cost reduction will not trickle down to patients.

PDABs have proven to be very challenging to implement, and none has yet reached the stage of generating savings for patients, states, or health systems. Implementation challenges create opportunities for process improvement in PDAB approaches to prescription drug selection and affordability reviews. During the ISPOR 2025 meeting in Montreal, an Issue Panel discussed the perceived issues that PDABs present, and three areas that present immediate opportunities for the development of best practices were outlined: 1) clearly defining affordability and PDAB goals; 2) data collection and analysis; and 3) meaningful stakeholder engagement.

1. Clearly defining affordability and PDAB goals

PDABs, at the outset of their work, have not clearly defined their affordability goals, and, for PDABs that have advanced to affordability reviews, this has created inconsistencies and tension later in the PDAB process. Focusing first on a robust discussion of the Board’s definition of affordability and its goals can create clarity for all stakeholders in the Board’s focus and intentions, while also establishing alignment for the following steps in the Board’s drug selection and review processes. Boards should implement systematic, reliable methods aligned to define affordability goals to ensure processes remain transparent, reliable, and consistent for all stakeholders. This should include conducting research to identify patient-reported affordability thresholds to serve as an evaluation marker.

2. Data collection and analysis

PDAB processes and methods rely heavily on data elements that are readily available for collection and comparison, such as health plan data calls and insurance claims contained within state all-payer claims databases. These data sources tend to be more routinely accessible since they are tied to reimbursement for all healthcare services, but they have a bias toward collecting cost measures and are, therefore, inherently limited as a sole data source. Reliance on these measures fails to capture broader clinical and societal impacts of treatments to patients, their families, and other stakeholders, particularly in the drug selection phase of PDAB work. In addition, PDAB discussions often focus on these data by relying on calculations of average costs, particularly patient out-of-pocket costs, which fail to contextualise aggregated data, and may lead to inaccurate and incomplete conclusions. Additional efforts should be made to collect and analyse additional real-world data (such as adherence and persistence, healthcare resource use avoidance, and disease progression) and to examine the underlying factors that relate to any specific data used by the Board.

3. Meaningful stakeholder engagement

For any affordability review, stakeholder engagement, particularly providers, patients, and caregivers, should be of paramount importance. PDABs should actively engage with key third-party stakeholders who may be impacted by PDAB decisions, including patients and caregivers, as well as patient advocacy organisations. These stakeholders, particularly those directly impacted by the disease, can provide meaningful insights on the value of eligible drugs, including prior to selection, during drug selection, and throughout an affordability review.

If advertisements around PDABs claim to focus on reducing costs for patients, then they should be designed to allow for improved and meaningful patient engagement, and outcomes should address patient-reported needs. However, current methods for collecting input from patients vary from PDAB to PDAB; similar questions lacked meaningful input, and, in turn, these methods may not reflect their lived experience or context related to potential affordability challenges.

Furthermore, a narrative was introduced early on that patient advocacy organisations should not be trusted solely on the premise that most get some of their funding from pharmaceutical companies. As a result, some PDABs have dismissed their expertise, while elevating credibility to others who represent patient voices and receive funding from other entities. This perspective is not only frustrating to organisations, but it is potentially damaging to the process of increasing patient engagement.

Due to the unique development processes of each state, there are currently no shared materials or best practices that could address the legitimate concerns of stakeholders; nor is there a clear mechanism for PDABs to collaborate and leverage their knowledge to enhance the processes.

State PDABs could serve stakeholders better if they could collaborate to develop and share the best practices, which would make processes more predictable, reproducible, and transparent. Patient engagement should be a key component of these efforts, with PDABs investing in question design development that could be used across boards and that are robust enough to capture the ‘why’ behind affordability successes and challenges. The benefit of PDABs to patients will only be realised when patients are at the center of a process that is designed to benefit them.

This article summarises Cencora’s understanding of the topic based on publicly available information at the time of writing (see listed sources) and the authors’ expertise in this area. Any recommendations provided in the article may not be applicable to all situations and do not constitute legal advice; readers should not rely on the article in making decisions related to the topics discussed. Panelists' opinions are their own and do not necessarily reflect those of their respective employers.

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Sources

Pharmapproach. Why are prescription drugs so expensive in the U.S.? Latest 2025 updates on drug pricing, Medicare negotiations, and cost-saving solutions. March 26, 2024. Accessed 15 August 2025. Available at: https://www.pharmapproach.com/why-are-prescription-drugs-so-expensive-in-the-u-s-latest-2025-updates-on-drug-pricing-medicare-negotiations-and-cost-saving-solutions/
Fick A, Shalal A, Graham D. Exclusive: US pharma tariffs likely weeks away as Trump plans for Alaska, sources say. Reuters. August 13, 2025. Accessed 15 August 2025. Available at: https://www.reuters.com/business/healthcare-pharmaceuticals/us-pharma-tariffs-likely-weeks-away-trump-plans-alaska-sources-say-2025-08-13/
The White House. Fact sheet: President Donald J. Trump announces actions to get Americans the best prices in the world for prescription drugs. July 31, 2025. Accessed 15 August 2025. Available at: https://www.whitehouse.gov/fact-sheets/2025/07/fact-sheet-president-donald-j-trump-announces-actions-to-get-americans-the-best-prices-in-the-world-for-prescription-drugs/

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