Beyond Prescriptions – BILHPN Pharmacy Program Updates
 

Medicare Drug Price Negotiation Program Impact for Patients in 2026

As part of the Inflation Reduction Act (IRA) of 2022, the Centers for Medicare and Medicaid Services (CMS) for the first time was allowed to negotiate drug prices directly with drug companies. This program, known as the Medicare Drug Price Negotiation Program, allows for the price reduction of several high-cost, highly utilized medications without generics. These price reductions would potentially be seen directly by the patient as they fill their prescriptions.


CMS selected ten drugs paid for under Medicare Part D for the first cycle of negotiations and reached agreement on lower prices – or maximum fair price (MFP) – that will go into effect January 1, 2026:

Medicare Advantage and standalone Medicare Part D plans are required to cover these medications as part of the IRA, although there are no specifications on how plans can implement utilization management rules (prior authorization, step therapy) or drug tiering.

 

Over the next few years, CMS will select additional drugs for negotiation, including 15 Part D drugs for 2027, 15 Part D or Part B drugs in 2028, and 20 Part D or Part B drugs for each subsequent year.

 

Key takeaways for Medicare patients beginning in 2026:

  • Medicare members struggling to afford these medications in 2025 should contact their plan during the current open enrollment period (October 15 to December 7) to inquire if the drug is still covered and may be more affordable in 2026. For example, if a patient is paying co-insurance (i.e., a percentage of the drug cost) for Eliquis during 2025, this may be considerably less expensive in 2026 with the lower maximum fair price.
    • Patients may also have the opportunity during open enrollment to switch to a plan with more preferred coverage.
  • Patients should be informed that they may have a deductible, which may be up to $615, they must pay before their copays take effect.
  • Insulin products will continue to be capped at $35 copay/month; patients should be prescribed the formulary covered insulin where clinically appropriate to take advantage of this discount.
  • If patients need further assistance, they may consider enrolling in the Medicare Prescription Payment Plan, which allows the medication costs to be distributed evenly over the course of the year. Patients should contact their Medicare Part D plan for enrollment.
  • For more information and fact sheets about the Medicare Drug Price Negotiation program, visit www. cms.gov.

Reference:

  1. IPD Analytics. Medicare Part D Formulary Strategy in 2026 – An Update.  November 2024.  Accessed October 2025.  https://www.ipdanalytics.com
Facebook XInstagramLinkedInYouTube