Fisher–Schultz Lecture: Contracting Over Pharmaceutical Formularies and Rebates

We investigate how formularies used by pharmacy benefit managers (PBMs) affect equilibrium manufacturer rebates for branded drugs through tiering and exclusion. We develop a theoretical model of multidimensional contracting in which a PBM negotiates with drug manufacturers over menus of formulary-contingent rebates and chooses a formulary. We then estimate consumer demand responses to tier placement for statins using claims data from Princeton University, a large employer contracting with a single PBM to offer prescription drug coverage to its employees. Combining the theoretical model with demand estimates and observed list prices, we quantify how allowing for differential tier placement and exclusion affect equilibrium rebates. Our predictions are consistent with available aggregate rebate data, and we find that allowing a PBM to place branded drugs on preferred- and non-preferred tiers can substantially increase negotiated rebate payments.