Nine More Drugmakers Signed MFN Deals. The Coalition Formed to Fight Them Did Not.
Nine manufacturers signed most-favored-nation pricing agreements on 31 August, taking the total to 26 and coverage to 89% of the branded drug market. Alcon, Astellas, BeOne Medicines, BridgeBio, CSL, Kyowa Kirin, Sun Pharma, Teva and UCB are on the list. Alkermes, Alnylam, BioMarin, Incyte, Madrigal and Travere are not.
The agreements give every state Medicaid programme MFN prices on the nine companies’ products and guarantee MFN pricing on every medicine they launch in future. Reference prices are set against net prices in eight high-income countries. The nine join 17 manufacturers who signed after letters went out on 31 July 2025, starting with Pfizer that September.
The nine committed at least $19.6 billion collectively to US manufacturing in the near term. UCB is donating 163 tons of levetiracetam to the Strategic Active Pharmaceutical Ingredients Reserve. Sun Pharma is contributing 71.4 tons of clindamycin and 6.75 tons of doxycycline, Teva 45 metric tons of metronidazole and 4.8 tons of amlodipine, Astellas 25 kilograms of tacrolimus.
Ten US biotechs formed the Midsized Biotech Alliance of America this year to contest the policy. None is among the signatories. The Council of Economic Advisers now puts total savings at $600 billion over the decade, up from the $529 billion projected in May.
A reader can stop here with the full picture. The sections below are the detail.
The alliance held
Ten US biotechs formed the Midsized Biotech Alliance of America this year for one purpose: to contest most-favored-nation pricing. Reported members include Alkermes, Alnylam, BioMarin, Incyte, Madrigal and Travere. Most market one or two products.
Their argument was arithmetic. A company selling thirty medicines can spread a reference-price cut across a portfolio. A company selling two cannot.
None signed.
This round was built for them. The White House described the nine as mid-sized manufacturers, and Bloomberg reported ahead of the announcement that the deals targeted companies left out of the earlier negotiations with large pharma. The administration reached 89% coverage without a single alliance member.
The companies that did sign look different. Alcon is headquartered in Switzerland, Astellas and Kyowa Kirin in Japan, CSL in Australia, Sun Pharma in India, Teva in Israel, UCB in Belgium. BridgeBio is the clear US name among them. Several carry substantial US manufacturing footprints, which changes what an MFN agreement costs against what it protects.
The fact sheet lists what the nine gave, not what they received
The White House document is precise on obligations. MFN pricing to every state Medicaid programme. MFN pricing on all future launches. At least $19.6 billion in near-term US manufacturing investment. Named tonnages of active pharmaceutical ingredient into a federal reserve.
It is silent on consideration.
Bloomberg reported before the announcement that tariff relief and possible exemption from Medicare pilot discount programmes were on the table. Neither appears in the fact sheet. Voluntary agreements are often announced without full terms, and the omission is not evidence that no consideration exists. It does mean the only publicly documented side of these deals is the side the manufacturers are paying.
The access angleFor the manufacturers still outside the programme, three things changed on 31 August. The Medicaid comparator moved, because state programmes now hold MFN prices across 26 manufacturers and any non-signatory prices against that benchmark rather than against historical net prices. The negotiating position weakened, because the administration demonstrated it can reach 89% coverage without the alliance. And the holdouts became enumerable: 26 named signatories against a public alliance membership list narrows the remaining 11% to a short roster that competitors, payers and reporters can all construct. The analysis that matters now is what an MFN agreement costs modelled against the eight-country reference basket, set beside what continued absence costs in Medicaid positioning.
The reserve donations came from the generic side of the house
Levetiracetam, clindamycin, doxycycline, metronidazole, amlodipine, tacrolimus. Every product donated to the strategic reserve is long off patent.
None comes from the branded portfolios the pricing agreements govern. They come from generic and established-products businesses, which is why the two largest tonnage commitments belong to Sun Pharma and Teva.
The scale gap is wide. UCB commits 163 tons. Sun Pharma commits just over 78 tons across two products. Teva commits nearly 50 tons across two. Astellas commits 25 kilograms. Tacrolimus is dosed in milligrams, so a smaller absolute figure is expected, but the headline numbers are not comparable quantities.
That establishes a second currency in these negotiations. A manufacturer with generic capacity can contribute physical supply to a federal reserve. A pure-play branded mid-cap has nothing equivalent to offer, which leaves price as the only variable on the table. That is one reason the alliance members may be harder to move than the nine announced on Sunday.
What to watch
Whether the tariff and Medicare pilot terms are published. Until they are, no party outside the negotiations can price an MFN agreement, and every subsequent signatory accepts terms the market cannot evaluate.
Whether an alliance member signs next. The coalition survived the round designed to capture it. A first defection would show the alliance was a negotiating position rather than a floor.
Whether the $600 billion estimate holds. It has risen from $529 billion in May, and that earlier figure was explicitly conditional on deals beyond the original 17. Those deals now exist, so the projection should stabilise. A further increase would warrant examination.
Eleven months separate the first MFN agreement, signed by Pfizer on 30 September 2025, from 89% branded market coverage. The remaining 11% is now a defined group of companies with a shared argument, no generic capacity to trade, and a public record of organising against the policy. Whether that constitutes leverage or exposure is the question their boards are answering this week.