Majority of Drugs Selected for Price Negotiation Are on ‘Preferred’ Tiers in Medicare

Major blood thinners are among the first 10 prescription drugs for which the Biden administration will seek lower Medicare prices as part of the Inflation Reduction Act (IRA). The negotiated prices will be announced on Sept. 1, 2024, and go into effect in 2026.

Medicare beneficiaries who filled prescriptions for the 10 selected drugs paid a total of $3.4 billion in out-of-pocket costs for those therapies in 2022. The Medicare program paid more than $50 billion for the drugs between June 2022 and May 2023, CMS reported. Bristol Myers Squibb’s blood thinner Eliquis (apixaban) alone accounted for more than $16 billion.

Several diabetes medications made the list: Boehringer Ingelheim and Eli Lilly’s Jardiance (empagliflozin), Merck’s Januvia (sitagliptin), AstraZeneca’s Farxiga (dapagliflozin) and Novo Nordisk’s Fiasp and NovoLog (insulin aspart). Under a provision of the IRA, there is already a $35 monthly cap on Medicare beneficiaries’ out-of-pocket costs for insulin.

For six of the 10 drugs, over half of Medicare beneficiaries have plans that put them on the preferred tier under the pharmacy benefit, according to a coverage policy analysis from MMIT Analytics (AIS Health is a division of MMIT). “Preferred” refers to product that is defined by the plan to be covered at the lowest level copay for brand products and most commonly includes preferred brands.

By Feb. 1, 2024, CMS will submit the maximum fair price of each selected drug to the drug manufacturer and the companies will have 30 days to respond to the initial offer by accepting it or providing a counteroffer.

However, the pharmaceutical industry has been fighting the Medicare Drug Price Negotiation Program for months. Drug manufacturers and lobbying groups have filed at least eight lawsuits against the Medicare drug negotiation process, arguing that those provisions of the IRA violate multiple parts of the Constitution.

This infographic was reprinted from AIS Health’s weekly publication Health Plan Weekly.

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