The Inflation Reduction Act’s Medicare Drug Price Negotiation Program

The Inflation Reduction Act's Medicare Drug Price Negotiation Program

The Centers for Medicare & Medicaid Services (CMS) recently unveiled transcripts from a series of patient-focused listening sessions, a pivotal element of the Inflation Reduction Act’s Medicare Drug Price Negotiation Program.

These sessions, conducted between Oct. 30 and Nov. 15, 2023, marked a significant step forward in the Program’s mission to make prescription drugs more affordable for Medicare Part D enrollees. Specifically, these sessions focused on the inaugural set of 10 drugs selected for negotiation, which treat a range of medical conditions, including diabetes, blood clots, heart failure, psoriasis, rheumatoid arthritis, Crohn’s disease, and blood cancers.

The drugs in question – Farxiga, Fiasp/NovoLog, Januvia, Jardiance, Eliquis, Xarelto, Entresto, Stelara, Enbrel, and Imbruvica – were chosen for their clinical importance and the financial burden they impose on patients. These sessions provided a platform for patients, caregivers, and representatives from consumer and patient organizations to voice their experiences, concerns, and hopes regarding access to these critical medications under the new negotiation framework.

While much of the public discourse surrounding the Medicare Drug Price Negotiation Program has revolved around the technicalities of the negotiation process, potential impacts on drug development, and legal challenges from pharmaceutical companies, less attention has been paid to the Program’s implications for Medicare Part D enrollees’ access to and utilization of these medications.

Key provisions of the law are designed to ensure broad access to these medications once negotiated prices come into effect in 2026. All Medicare Part D plans will be required to cover each of the negotiated drugs in all available dosages and forms. Furthermore, CMS will closely monitor and regulate the placement of these drugs on formulary tiers, ensuring that any decision to place these drugs on non-preferred tiers, which typically involve higher cost-sharing for patients, is well-justified.

Additionally, CMS aims to curtail the use of utilization management tools like prior authorization requirements for these drugs, potentially easing administrative hurdles and facilitating easier access to these medications for enrollees. Despite the currently high coverage rates for most of these drugs across Part D plans, variations do exist, particularly in the coverage of different dosages and forms. For example, while nearly all enrollees have access to Xarelto tablets, coverage for its oral suspension drops to 78 percent. Similarly, coverage varies for different forms of Imbruvica, with a slight decrease in coverage for higher-dosage forms. As the Medicare Drug Price Negotiation Program moves forward, these measures reflect a comprehensive approach to not only lowering drug prices, but also ensuring that enrollees have the access they need to critical medications. This balanced focus on affordability and accessibility highlights the Program’s potential to significantly impact the lives of millions of Americans reliant on Medicare Part D for their prescription drug coverage.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Timothy Powell, CPA, CHCP

Timothy Powell is a nationally recognized expert on regulatory matters, including the False Claims Act, Zone Program Integrity Contractor (ZPIC) audits, and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance. He is a member of the RACmonitor editorial board and a national correspondent for Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 SDoH Update: Navigating Coding and Screening Assessment

2024 SDoH Update: Navigating Coding and Screening Assessment

Happy World Health Day! Our exclusive webcast is just $99 for a limited time! Use code WorldHealth24 at checkout before April 12th to claim this discount.

Dive deep into the world of Social Determinants of Health (SDoH) coding with our comprehensive webcast. Explore the latest OPPS codes for 2024, understand SDoH assessments, and discover effective strategies for integrating coding seamlessly into healthcare practices. Gain invaluable insights and practical knowledge to navigate the complexities of SDoH coding confidently. Join us to unlock the potential of coding in promoting holistic patient care.

May 22, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →