One of the biggest challenges Independent Brokers have with clients regarding plan selection is the cost of their prescription drugs. This has been an ongoing problem for many and can drastically affect access to affordable health care plans. The steep price tag on medications such as Eliquis and Jardiance has also led to problems accessing these lifesaving and sustaining drugs. Clients have shared in some cases that they just won’t take their medication. They simply cannot afford it. While there are other options for financial assistance we can seek out, not everyone qualifies. Strides have been made so far to address this including the $2000 annual cap on drug copays that began this year. However, more is coming! So, what is on tap next to address this issue?
Medicare Drug Price Negotiation Program
As announced with the Inflation Reduction Act of 2022, CMS was granted the ability to negotiate pricing with the pharmaceutical companies and manufacturers for certain highly utilized, high cost drugs. The drugs were identified based on cost, severity of chronic illness being treated, utilization and were limited to those that do not have a generic or biosimilar alternative. In 2024, negotiations began for the 10 identified drugs with the goal of implementation in 2026. Remember, we are talking about the fast moving government entities…wink, wink. There is already work in progress on the next round of 15 drugs identified for implementation in 2027. This has been quite a process and has been heavily publicized in the last two years. However, we are finally close to its actual implementation, slated for January 1st, 2026! So here is how it happened and what to expect next year with the first round.
Let’s Negotiate
Negotiations began in February of 2024 with CMS putting out initial offers to makers of those 10 identified drugs, taking into account what the statute refers to as Maximum Fair Prices. Analysts claim they also considered the cost support for innovation and drug development. The drug companies then made counter offers in pricing with data driven justifications. And on it went for three meetings with each manufacturer for each of the 10 drugs. In the end, an agreement was reached for all 10 drugs. So without further delay, here are the 10 drugs and their new negotiated prices for 2026.
Drug List for 2026
**All prices are for a 30 day supply**
Januvia by Merck – Original Price $527, New Price $113.00
NovoLog PenFill by Novo Nordisk – Original Price $495, New Price $119
Farxiga by AstraZeneca – Original Price $556, New Price $178.50
Enbrel by Immunex – Original Price $7,106, New Price $2,355
Jardiance by Boehringer Ingelheim – Original Price $573, New Price $197
Stelara by Janssen Biotech -- Original Price $13,836, New Price $4,695
Xarelto by Janssen -- Original Price $517, New Price $197
Eliquis by Bristol Myers Squibb -- Original Price $521, New Price $231
Entresto by Novartis -- Original Price $628, New Price $295
Imbruvica by Pharmacyclics -- Original Price $14,934, New Price $9,319
Other Considerations
You may look at those prices and think that is still quite a hefty price tag for many people. But remember, this is a starting point. The Part D Plan or Advantage Plan which includes Part D will cover a portion of the cost as well. So that number above may not exactly translate to what the consumer pays. There are more negotiations happening between Part D insurance carriers and actual pharmacy delivery systems such as retail pharmacies, mail order pharmacies and pharmacy benefit managers. CMS has successfully lowered the starting price which will hopefully lower the overall cost share for Medicare beneficiaries. It is projected to save beneficiaries enrolled in a Part D Plan an estimated $1.5 Billion and save Medicare an estimated $6 Billion dollars.
LOOKING FORWARD
We still don’t know how this will look on the Stand Alone Drug Plans and pricing on Advantage Plans for 2026. These 10 drugs are required to be on all Part D plan formularies. That may have an impact on Part D plan premiums and other benefits on Advantage Plans. So, insurance brokers and agents will always remind you to watch for your Annual Notice of Change from your plan in September. It will have more details on how the pricing affects you and your plan. Another concern to watch for is that some retail pharmacies may have trouble stocking these medications due to the ripple effect of price negotiations. Despite any ripple effects, the goal is to help critical access for Medicare beneficiaries to their needed medications.
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
Resources:
https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation
