As we rang in the new year, we passed a significant milestone in the Medicare Negotiation Program. Quietly and without much fanfare, the Maximum Fair Prices (MFPs) for the first 10 Part D drugs selected for negotiation went into effect on January 1st, collectively referred to by their initial price applicability year (IPAY 2026).
This year, seniors will begin to see the impact of the negotiation program for the first time, not just through lower reimbursement rates tied to these drugs, but also in how insurers respond to those reduced rates. While patient costs could go down, plans may also make significant changes to coverage, including formulary placement, tiering, and utilization management requirements.
In its own guidance on the negotiation program, the Centers for Medicare and Medicaid Services (CMS) has acknowledged these risks and warned that plan behavior could directly affect patient access:
“CMS is concerned that Part D sponsors may be incentivized in certain circumstances to disadvantage selected drugs by placing selected drugs on less favorable tiers compared to non-selected drugs, or by applying utilization management that is not based on medical appropriateness to steer Part D beneficiaries away from selected drugs in favor of non-selected drugs.”
As a result, seniors could face non-medical switching, which is when a patient’s medication is changed due to insurance or cost reasons instead of medical need, or lose access to their preferred medication altogether. Importantly, these changes may affect not only patients taking the negotiated drugs, but also those taking medications in the same therapeutic class, as plans seek to steer patients toward alternatives.
At the same time, another equally significant milestone has arrived. On January 27, CMS announced the 15 drugs selected for IPAY 2028 – the first time Part B drugs were eligible for inclusion in the negotiation program. Of the 15 selected, six are covered under Part B.
Part B drugs are administered by medical professionals through infusions in physician offices or outpatient settings. They include many chemotherapy treatments, autoimmune therapies, and other specialty medications that are critical for patients with serious and chronic conditions.
To provide these treatments, physician offices must purchase the drugs upfront and are later reimbursed by Medicare at a set rate. Over time, these reimbursement rates have steadily declined, leaving many practices struggling to recover their full costs, particularly smaller, community-based providers.
For drugs selected for negotiation, reimbursement will be tied to the MFP, which is expected to be lower than existing payment rates. This could force physicians into an untenable position: either stop offering these medications altogether or absorb financial losses in order to continue treating their patients.
CCPA has been, and will continue to be, closely engaged with patients, allied organizations, and CMS as the negotiation program is implemented. We urge patients and our partners to participate in the public information sessions scheduled for this spring on the IPAY 2028 drugs.
In the meantime, Congress must closely monitor how this program affects patients and their access to medically necessary treatments. We also urge caution against efforts to expand the negotiation program before its real-world impacts are fully understood. Proposals to significantly increase the number of medications selected each year are premature, particularly given that the first negotiated prices only took effect this January.