Ho, Ho. Ho, Ho. It’s likely back to work you go. If you checked out the last week, here is what you might need to know before you get too far into your week. I will have the regular AMP is WAC on Friday but a catch-up felt in order.
Waiting Game. The rollout of President Trump’s response to the expiration of the Affordable Care Act subsidies was supposed to be announced last Monday but was delayed.
To Care, Or Not to Care, That is the Question. On November 25, the Centers for Medicare and Medicaid Services (CMS) released the Contract Year (CY) 2027 Medicare Advantage and Part D proposed rule. At the heart of the proposal is the codification of the Inflation Reduction Act. There seems to be some minor changes around transparency in coverage determinations and prior authorizations and then a focus in Star Ratings on outcomes and patient experiences. The hmmm… moment comes with the loosening of marketing requirements. Because that has worked out so well in the past? More to come but that’s all based on my first read.
Math for Politics. Last week CMS also released the prices and savings for the 15 drugs negotiated for 2027. The release said that the drugs accounted for $42.5 billion in total gross covered prescription drug costs. The fact sheet said that if these negotiated prices had been in effect during 2024, they would have saved an estimated $12 billion in net covered prescription drug costs. Sigh. No. I’d write more about this but just read this from Adam Fein. The other head scratcher that will need to be worked out is that the MFN prices for the GLP-1s are lower than the negotiated prices. It is like a matter of timing but…
Other negotiation news — The Drug Price Negotiation ICR for 2028 drugs can be found in the Federal Register. Comments are due by December 24. CMS announced that Stelara, Entresto and Xarelto will only have negotiated prices for 2026 because of generics/biosimilars.
OPPS Here. If the hospital outpatient rule is your thing, this from the American Hospital Association could help you catch up.
