When CMS on Aug. 15 revealed the prices of the 10 drugs subject to Medicare price negotiation, its much-anticipated disclosure still left many questions unanswered. In the managed care world, the biggest question mark remains how Medicare Part D plans will adjust their formularies in reaction to the new government-set prices — but one industry expert says it will be a while before more clarity emerges.

“These prices are effective Jan. 1, 2026, so they should not, in theory, impact the 2025 formularies,” which have been largely decided since April, says Jennifer Snow, founder of the health policy and reimbursement consulting firm Apteka LLC.

While the Inflation Reduction Act (IRA) had multiple provisions affecting a variety of industries, including energy, agriculture and manufacturing, the prescription drug aspects of the law have arguably gotten the most attention, both positive and negative. Those provisions impact several industry stakeholders, with pharmaceutical manufacturers and health insurance plans in particular shouldering new responsibilities. In response, Medicare plans are expecting to take various actions, such as increasing premiums, and even commercial plans have begun to modify their drug management approach, according to research from Zitter Insights.

With the Medicare Part D national average monthly bid amount (NAMBA) set to spike 180% next year, CMS late last month unveiled a new demonstration program aimed at stabilizing a market that is experiencing unprecedented volatility.

However, some Republicans in Congress are up in arms over the demonstration, arguing that it contains “extra-statutory, eleventh-hour policy changes” aimed at cleaning up a problem created by the Biden administration’s most-touted health policy achievement.

CMS released the first set of negotiated prices for 10 drugs with the highest total gross Part D spending, as directed by the Inflation Reduction Act (IRA). The agency published the list of 10 drugs selected for Medicare price negotiations a year ago and on Aug. 15 posted the maximum fair prices reached with manufacturers, reflecting discounts that range from 38% to 79% off of list price. The negotiated prices will take effect in 2026 and are expected to generate an aggregated savings of $1.5 billion in out-of-pocket costs for seniors. CMS estimated that about 9 million people with Medicare use at least one of the 10 negotiated drugs, which include highly utilized brand-name drugs Eliquis (apixaban) for the prevention and treatment of blood clots and Jardiance (empagliflozin) for the treatment of diabetes, heart failure and chronic kidney disease. CMS will continue to engage in price negotiations on select high-cost Part B and Part D drugs for future years.

Along with other major changes to the Medicare Part D benefit, beneficiaries starting next year will have a $2,000 limit on their annual out-of-pocket (OOP) prescription drug costs, thanks to the Inflation Reduction Act (IRA). If seniors find themselves uncomfortably close to that threshold, they also can smooth those OOP costs over the course of the 2025 plan year through the IRA-established Medicare Payment Prescription Plan (M3P) program. While sources agree the program has the potential to improve access to prescription drugs, they say its success is also largely dependent on how well plans inform patients that the option is available.

With the Medicare Part D national average monthly bid amount (NAMBA) set to spike 180% next year, CMS late last month unveiled a new demonstration program aimed at stabilizing a market that is experiencing unprecedented volatility.

However, some Republicans in Congress are up in arms over the demonstration, arguing that it contains “extra-statutory, eleventh-hour policy changes” aimed at cleaning up a problem created by the Biden administration’s most-touted health policy achievement.

Following an unprecedented year-over-year increase in 2024 stemming from provisions in the Inflation Reduction Act (IRA), the Medicare Part D national average monthly bid amount (NAMBA) is projected to increase by $115, or nearly 180%, to $179.45 in 2025. That number reflects big changes to the Part D benefit, such as the government passing more risk to Prescription Drug Plan (PDP) and Medicare Advantage Prescription Drug (MA-PD) sponsors, but it doesn’t mean the full bump in estimated costs will be passed onto consumers. At the same time, the federal government on July 29 unveiled a new demonstration opportunity for PDPs intended to provide additional premium stability across the Part D market.

The NAMBA — an enrollment-weighted average of the estimated cost to Part D plan sponsors of providing the basic benefit package — was always expected to increase because of benefit changes taking effect next year; it was just a question of how much higher it would be.

Medicare Advantage Prescription Drug plans (MA-PDs) continued to gain more enrollees than stand-alone Prescription Drug Plans (PDPs) in 2024, according to a KFF analysis.

As of 2024, about 53.1 million Medicare beneficiaries were enrolled in a plan with Part D prescription drug coverage, with 57% in MA-PDs and 43% in stand-alone PDPs. Two-thirds of enrollees receiving the low-income subsidies (LIS) — 9 million out of 13.7 million — chose MA-PDs in 2024. Among the 14 national PDPs, 11 of them lost non-LIS enrollees, with only Wellcare Value Script seeing significant membership growth (from 2.6 million to 3.7 million) due to its low monthly premium.

CMS’s Medicare Advantage Value-Based Insurance Design (MA VBID) model — which offers MA organizations enhanced flexibility to tailor a variety of interventions to address health-related social needs — has gone through multiple iterations since its inception. In what CMS officials consider the third phase of its evolution, MA VBID participants will soon face new accountability for driving savings, addressing health equity and delivering meaningful supplemental benefits.

The MA VBID model, which was launched by the CMS Center for Medicare and Medicaid Innovation (CMMI) in 2017, has seen participation grow from nine MA organizations in three states to 69 MAOs serving an estimated 8.7 million VBID beneficiaries across the U.S. Having been extended through 2030, it is currently CMMI’s longest-running model and the only model specifically testing innovations in MA. Those innovations initially included offering supplemental benefits or reduced cost sharing to enrollees with certain chronic conditions or who participated in care management and/or disease management activities.

After considering stakeholder feedback on its draft second guidance for the Medicare Prescription Payment Plan, CMS on July 16 released final guidance that gives plans more flexibility around identifying Part D enrollees who are likely to benefit from the M3P. Starting next year, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. After finalizing its first guidance in February, CMS released a draft of the second installment, with a public comment period that ran from Feb. 15 through March 16. CMS in a July 16 memo to plan sponsors said it received more than 100 responses from a broad range of stakeholders, including patient advocates, data vendors, Part D sponsors and pharmacy benefit managers, and it made several clarifications and changes in response. Those included clarifying that it does not expect Part D plans that exclusively charge $0 cost sharing for covered Part D drugs to all plan enrollees to offer members the option to spread out their OOP costs through the M3P and giving plans the option to send an election request form with the member’s ID card mailing or separately in a different mailing. The agency also will allow plans to develop their own strategies for ongoing outreach during the plan year to enrollees who are likely to benefit from the M3P. CMS on July 16 also released a final set of model and standardized materials to support Part D sponsors in meeting their education, outreach and communications requirements for the program.