Government Payers

The Centers for Medicare and Medicaid Services is considering imposing price inflation rebates on Part B drugs furnished to enrollees in Medicare Advantage plans in addition to those covered by fee-for-service Medicare.

Doctors are increasingly falling victim to financial scams due to their high incomes, busy schedules, and trust in professional networks. Recognizing the tactics scammers use and the reasons behind physicians’ susceptibility is essential for protecting medical professionals.

US lawmakers will undoubtedly continue to work on pharmacy benefit manager reform legislation in 2025, given its bipartisan support. But policies impacting rebates that could lead to higher premiums in Part D may be a tough sell in the midst of the benefit redesign.

Medicare coverage with evidence development final guidance includes few substantive changes from the proposed version despite biopharma stakeholder concerns.

Congressional Budget Office responses to questions from US lawmakers on pharmacy benefit managers could add to the momentum for PBM reforms to go further than the current leading proposals.

Pink Sheet reporter and editors discuss the take-aways from the landmark first Medicare negotiated drug prices and what additional information remains outstanding.

But the amount of savings realized when the Medicare negotiated prices go into effect in 2026 remains the subject of debate.

CBO estimated Medicare would get 50% net price reductions under the IRA, but CMS actually garnered 22%. The CBO analysis could not account for some of the particulars of the negotiations, but some health policy experts stressed any net gain over private Part D plan negotiation is a win.

Some manufacturers may have the dubious distinction of being targeted in the first and second rounds of the negotiation program, but at least will be familiar with the process the next time.

Net per drug savings achieved by the negotiation process is unclear because many of the products already have significant rebates. The announcement also leaves much of the agency’s negotiation process in the dark.

The CMS supplemental reimbursement for the gene therapies is higher than usual for new technologies, but is similar to the formula used for antibiotics.

The analysis was released days before the Biden Administration is expected to announce a reduced Medicare Part D price for Johnson & Johnson’s immunosuppressant resulting from the government negotiation program established by the Inflation Reduction Act. 

Manufacturers likely will have to determine when to provide a 340B discount on a drug assigned a Medicare negotiated price under CMS guidance. PhRMA anticipates the job will not be easy.

It is not yet clear how much premiums may increase in standalone enhanced Medicare Part D plans for 2025 because the demonstration is designed to blunt the financial pressures imposed by the Inflation Reduction Act’s benefit redesign.

The US Medicare agency is creating a formal reconciliation process for new inflation rebates in Part B and Part D of the program.

Second generation combination products may become more appealing as companies navigate the complexities of the Medicare price negotiation program.

Vertex’s fertility preservation assistance program would provide up to $70,000 in financial support for in vitro fertilization and other services to patients prescribed Casgevy.

A number of diabetes drugs are also expected to be targeted in the next cycle of the price negotiation program, led by Novo Nordisk’s Ozempic.

A US House of Representatives bill to provide obesity drug coverage to a very select group of Medicare beneficiaries, passed only after Democrats debated whether the proposal is a “first step” towards broader coverage or a misstep counter to Medicare’s goals.

Akebia says its price for Vafseo at about $15,500 per year, meant to reflect its potential value in dialysis as well as eventually in non-dialysis patients.