More Than Just Pricing: MFN’s Impact on Pharma: Q&A with Lindsay Bealor Greenleaf

With the launch of TrumpRx earlier this year, Americans got their first taste of how the administration is attempting to implement its most favored nation (MFN) pricing policies. Lindsay Bealor Greenleaf, head of market access policy strategy at ADVI, spoke with Pharmaceutical Executive about the current state of MFN and how the industry expects it to impact operations as more of the policies come online.

See the video version of this interview here!

Pharmaceutical Executive: How does MFN pricing work within TrumpRx?
Lindsay Bealor Greenleaf: The two are certainly related, but I view them differently. One thing to point out is that the Trump RX website where patients can go is basically a direct-to-patient program. It's also a place where patients, whether or not they're getting access to a drug in a direct to patient format, can also have access to coupons and discounts.

The website is live. There's over 40 drugs that are on there. I think it's off to a great start, and it's helping a lot of patients. The launch of Trump RX coincided with a number of the MFN deal announcements that we had at the end of 2025, so when I think of Trump RX and MFN pricing, a lot of the prices that are on Trump RX do correspond to what may be an MFN price for a given drug, but not necessarily either.

It's meant to be a bigger, broader program focused on how to get patients access to the lowest cash pay price or greatest, coupon or discount that they can access. It will be a more seamless experience: go to one website, one stop shop, that sort of thing. MFN pricing overlaps, but it’s not necessarily a perfect correlation for all the drugs on TrumpRx.

Pharmaceutical Executive: How might MFN impact patient access through Medicaid?
Lindsay Bealor Greenleaf: The MFN policies that have been proposed related to Medicare Part B and Medicare Part D, they could have significant impacts on access and the future for innovation going forward. However, where we stand, those are proposals, so I’ll speak to where we are right now.

You have 16 companies that have entered into these voluntary deals with the White House HHS, and CMS. They are agreeing to voluntarily provide MFN pricing on behalf of Medicaid patients. They're also agreeing to have future launches correspond with an MFN price going forward, and a number of other things as well.

Those things have to do with TrumpRX and tariff exemptions. Some companies got FDA priority review vouchers as well. Everybody's deal looks a little bit different, and the full details are confidential.

So, we're going with what we know and what folks have put in their press release. For MFN policies that are in place right this second, it's what companies have agreed to on a voluntary basis. With regard to Medicaid, the way that that MFN price would be achieved would be through a rebate construct. The Medicaid program would receive an MFN price on net, with the manufacturer basically cutting a check for the government.

Patient out of pocket costs in Medicaid are not much of an issue. Typically, patients are paying anywhere between $4 and $8 at the pharmacy counter for their prescription drugs. There's not an impact on patient out-of-pocket costs or patient access, necessarily. In the Medicaid program with these voluntary deals, the impact is felt squarely on the manufacturers specifically.

Pharmaceutical Executive: How will the MFN impact on Medicare impact innovation?
Lindsay Bealor Greenleaf: What we are most focused on (and most concerned about) is what has been proposed on a mandatory basis for the Medicare program: the physician administered drugs under Medicare Part B and then the pharmacy benefit products under Part D. When thinking about patient access and broader scale stakeholder implications of those two proposals, we're very concerned about the innovation impact that would occur if those two policies are finalized.

One thing they share with the Medicaid policy is that the MFN prices would be achieved through a rebate approach. That takes providers out of The Mix, for the most part, we're not going to have provider impact implications with these MFN policies and Medicare. That's a change from how President Trump's team proposed doing this under their first term.

Back in 2018 and 2020, when they were first talking about MFN, there were going to be some significant provider reimbursement implications included, but that's not on the table. There is a patient access and out-of-pocket concern tied to these policies as proposed today, most notably the Part D MFN (we call it the guard model) that has been proposed. EMS projects that it would result in patient out-of-pocket, with costs going up $3.6 billion over the course of the model. That is a lot of money.

They have complex reasons why this would be, but basically, it has to do with planned bid interactions. So, this is not necessarily something helpful for patients.

These models would hit on Trump's talking points of wanting to address this perception of higher prices here in the US. It would achieve that, but we do have real concerns for what it would mean for patient out-of-pocket costs. And of course, there are the concerns of what it’s going to mean for innovation going forward, with fewer drugs to launch in the future.

Pharmaceutical Executive: What potential fallout will MFN policies have?
Lindsay Bealor Greenleaf: The fallout from these policies lies squarely on the concerns around innovation and drugs launching in the future. There were some projections back in 2020, when the Trump led CMS proposed doing a MFN policy just for Medicare, Part B drugs. There was an American Action Forum projection back then that said just focusing on Part B with MFN pricing would result in 60 fewer drugs to launch over the next decade. That's just the Part B drugs.

We're always on the hunt for new projections like that, and some folks on our team are actually working on our own projection for what this might mean for launches going forward. I'll have some updated numbers for you soon, but you can imagine just 60 drugs being just the medical benefit of those physician administered drugs.

This is something that is being proposed, not just for those medical benefit drugs, but also on the pharmacy benefit side. It's concerning from an innovation perspective. So, that's the biggest fallout. The other thing to point out that manufacturers are trying to wrestle with here is the potential for these MFN Medicare policies to be finalized in the context of everything else that's going on.

We're often talking about MFN all day, but it's also inflation reduction act (IRA) all day. We're talking about IRA government negotiation, and the fact that there are 10 drugs with a negotiated price, or a CMS set price.

In 2027, there’s another 15 drugs, and then another 15 after that, We're going to have a lot of drugs subject to these negotiated/CMS set prices. That's having a huge impact on launch planning, R&D, and capital for new investments.

You also have layered on top of the IRA negotiation concerns the 340 B program. This is huge for our clients, and it's just not talked about enough. The 340 B drug discount program (where the majority of American hospitals and pharmacies contract with) have access to massive discounts, including statutorily mandated discounts that manufacturer must provide on an upfront basis, sometimes roughly 50% off the price of a drug.

As of today, one-in-four drugs flows through a 340 B entity. One-in-four drugs is subject to the statutory mandatory discounts.