Going crazy? Or is it just a party of one? This past month as been brutal. My house has been a parade of plumbers and HVAC and electricians. Plus, visits to orthopedists and veterinarians and car mechanics. If the universe is trying to say something, all I’m hearing is that I’m scoring a ton of airline miles on my credit card. Bonus points for work being quiet, am I right?!?
Sigh.
Caught My Eye
They Multiplied. First there was the GLOBE (Global Benchmark for Efficient Drug Pricing (GLOBE) model and now there is GUARD (Guarding U.S. Medicare Against Rising Drug Costs). Twice the fun to keep an eye out for in terms of Most Favored Nation pharmaceutical pricing.
Blink and You’ll Miss the Conflict of Interest. The Wall Street Journal reported that there would be a meeting of pharmaceutical manufacturers in DC hosted by BlinkRx. The same BlinkRx that has Donald Trump Jr. on its board. And the same BlinkRx that happens to be in online prescription drug delivery which coincidentally (*wink wink*) is a priority of this current Administration.
Not as Bad as It Could Be. KFF has an analysis on the Medicare prescription drug plan market for 2026. As expected, there are way fewer standalone prescription drug plans (PDPs) – 20% decrease. We went from 464 to 360. Monthly premiums are all over the place depending on the state, with some enrollees seeing $50 increases and others seeing reductions in premiums. There will be about the same number of low-income subsidy plans (2 – 4 in most states.) Some fun charts to poke through if that’s your thing.
The Math Doesn’t Work. Late last week Colorado implemented the country’s first upper payment limit. Waiting to see how fast access to Enbrel is restricted. Upper payment limits do not change what a drug company sells the drug at; it limits what the state is willing to reimburse for it. I tried that today when I needed a new water heater. I told him that I’d only pay $3,000 – not the $4.5k quoted. He can charge what he wants, but why should I pay it? Right? So now it’s cold showers all around. Kidding. I handed over my credit card and cried a little inside.
Paused? With the government shut down, it is possible that the 340B rebate model pilot program will be delayed. Super short window, further crunched. And this week’s MedPAC meeting was cancelled.
Reviewing the Fundamentals – Medicare Part D and Extra Help
As we edge toward Open Enrollment (October 15), I thought it might be helpful to talk about the Medicare Part D Low-Income Subsidy (LIS), commonly referred to as “Extra Help.”
The Extra Help program was established as a component of the Medicare Part D prescription drug benefit. It serves as a federal financial subsidy intended to help individuals with Medicare afford premiums, deductibles, and copayment. The program’s eligibility is administered by the Social Security Administration (SSA), with the Centers for Medicare & Medicaid Services (CMS) overseeing the benefit structure.
Qualifying
To qualify for Extra Help, a beneficiary must be enrolled in or eligible for a Medicare prescription drug plan (Part D) and must meet federal income and resource limits.
Many beneficiaries receive Extra Help automatically and are not required to submit an application. This automatic enrollment applies to individuals with Medicare who are also receiving:
- Full Medicaid coverage.
- Supplemental Security Income (SSI) benefits.
- Assistance from their state in paying Medicare Part B premiums through a Medicare Savings Program (MSP).
For those who do not automatically qualify, the process to enroll in Extra Help is handled by SSA. An application (Form SSA-1020) can be submitted at any time of the year.
Beneficiary Cost-Sharing
The Extra Help program provides financial relief for beneficiaries:
- Premiums: The monthly Part D premium is $0 if the beneficiary selects a benchmark plan in their region.
- Deductible: There is no annual deductible.
- Copayments: Beneficiaries pay low, fixed copayments, not exceeding $12.65 per drug (for 2026.)
Plan Selection
Extra Help recipients are eligible to enroll in any available Part D plan in their area, including Stand-alone Prescription Drug Plans (PDPs) and Medicare Advantage Plans with drug coverage (MA-PDs).
While beneficiaries have access to any Part D plan, the number of plans that are available for a $0 monthly premium (benchmark plans) is more limited and varies by state. For example, in 2026, the number of premium-free benchmark PDPs is projected to range from 1 to 4 across the various states with more states having 2 – 4 plan options. If a beneficiary chooses a non-benchmark plan, they must pay the difference between the plan’s premium and the government’s subsidy amount.
Individuals who qualify for Extra Help but have not yet selected a Part D plan are subject to auto-enrollment by Medicare. Beneficiaries with Extra Help have a Special Enrollment Period (SEP), allowing them to switch to a different Part D plan, generally once per month, if the auto-enrolled plan does not meet their needs.
For the Files
Health Affairs Forefront summary of the 2028 final guidance on Medicare negotiation. I have the 381-page document in a binder on my desk. I am not willing to give up … yet. But I’m close.
