A consequence of the “new” PBM model is higher US drug prices, initially.One of the consequences of the “new Pharmacy Benefit” (PBM) model in the USwhich has emerged over the last few years, where PBM consolidation has resulted inPBMs gaining pricing power at the expense of Pharma companies, is that new drugprices are initially notably higher in the US. As competition in each therapy classemerges, higher rebates demanded by PBMs in return for continued formularyaccess mean that net drug prices are likely to remain under pressure.    Parallels between US and Japanese drug pricing. In our view, this increases thesimilarities between the US and Japanese drug price structures. In Japan, new drugsare launched at high prices in the expectation that the biennial price cuts will erodethe price of drugs in due course. In the US, the “new” PBM model in effectencourages drug launches at high prices since Pharma companies should expect tohave to provide higher rebates in due course when competition emerges i.e. effectiveprice cuts on potentially an annual basis.    Drug price inflation will likely be more muted and price deflation set to continue.A second consequence of the “new” PBM models is that drug price inflation will likelybe more muted than in the past in the US (enforced by formulary exclusion, not bycorporate discipline). Further, drug price deflation is now becoming structurallyembedded in the US system in competitive therapeutics areas – and in some cases,this has occurred within a few months of an innovator drug being launched.    The alignment of PBM, Pharmacies and Distributors unlikely to help drugpricing. The recently announced collaborations (in May) between Pharmacy chainWalgreens (WBA US, USD67, not covered) and drug distributor McKesson (MCKUS, USD134, not covered) on generic drugs and the collaboration between the PBMExpress Scripts (ESRX US, USD59, not covered) and the Pharmacy/distributor JVWalmart Boots Alliance will likely help strengthen that structurally embeddedpressure on US drug prices.

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