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Much of our previous state Medicaid program drug pricing work has been concentrated on diagnosing and sizing a largely overlooked practice called “spread pricing.” The tactic, typically deployed by pharmacy benefit managers (PBMs), involves a PBM paying a pharmacy one price for the dispensing of a prescription, billing a different rate back to a plan sponsor, and pocketing the difference as a spread. As this massive cost-driver is eliminated from state Medicaid programs across the country, 3 Axis Advisors was asked to analyze 350+ million claims worth of pharmacy data in the Florida Medicaid program to assess spread’s influence on the state’s drug costs. Our analysis found very little spread pricing in the program up until 2025, where it appeared to be all but eliminated. However, in our research, we found a slew of other perplexing practices embedded in the prescription drug supply chain that highlight several warped incentives, pricing distortions, and conflicts of interest that stand to drive up costs and compromise robust provider access. As spread pricing is eliminated from more state programs, this report highlights how PBMs and MCOs pivot their pricing and management of pharmacy benefits in a post-spread world.

In 2018, the U.S. Department of Health and Human Services (HHS) released a report detailing Medicare Part D spending on brand-name drugs that were also available as multi-source generics. At the top of that list was a popular medication known as Nexium, for which Medicare spent $1.06 billion (pre-rebate) in 2016, despite its manufacturer losing its patent exclusivity in early 2015.

Motivated to understand the root cause of the elevated spending on this high-profile brand-name drug in 2016, we started to research the story of Nexium, and the old drug from which it was derived, Prilosec. We struggled to find a comprehensive overview of the entire Nexium story that was supported by data and analytics needed to fully understand its many moving parts. To fill this void, we received funding from Waxman Strategies through a grant provided by Arnold Ventures to complete and publish this work. Our goal was simply to provide a full data-driven analysis of the Nexium story to help educate lawmakers and the general public on how a drug commonly viewed as a line extension first became a blockbuster drug for AstraZeneca and then exposed a host of warped incentives across the U.S. drug supply chain that continue to be exploited today. The information in this report can serve as the foundation for a more constructive debate on what regulation is needed to help reduce waste in the drug supply chain without sacrificing innovation.