Senate Democrats Pass Climate, Tax and Health Care Bill… What are the Implications for Pharmacy?

NCPA August 7, 2022

The Senate on Sunday passed the Inflation Reduction Act, and the bill includes provisions that should impact community pharmacy. The bill now heads to the House which will take it up on Friday, August 12. Here is what we know so far:

  1. Starting in 2026, the HHS Secretary would negotiate pricing for the 10 top-spend drugs in Medicare Part D, many of which are dispensed in community pharmacy, and would increase the number of drugs negotiated yearly and include Part B drugs by 2028.

  2. For pharmacies, reimbursement could be impacted under the new price negotiation framework, as any difference between the negotiated price and discounted price for a drug would be “trued-up” within prompt pay requirements. NCPA continues to work with our champions to clarify that no reduction in pharmacy reimbursement will occur because of Medicare drug price negotiation.

  3. Annual out-of-pocket cap. Out-of-pocket costs for Medicare Part D beneficiaries would be capped at $2,000 per year in plan year 2025. In subsequent years, the $2,000 threshold will be increased at the rate of growth for the Part D program.

  4. Optional “smoothing” of patient cost sharing. Starting in 2025, Part D patients can elect to have their cost sharing smoothed out over the course of the benefit year. The growth in Part D premiums is capped at 6% per year from 2024 to 2029.

  5. Vaccines. Cost sharing for adult vaccines covered under Medicare Part D is eliminated beginning January 2023 and access to adult vaccines under Medicaid and CHIP is improved.

  6. Drug rebate rule. The drug rebate rule is delayed to 2032, which Democrats are using once again as a budget gimmick to offset the cost of the legislation.

  7. Drug rebates. Beginning in 2023, drug manufacturers must provide rebates for certain Medicare Part B drugs whose cost outpaces inflation.

  8. Insulin. Monthly copayment spend on insulin is capped at $35 for plan years 2023, 2024, and 2025 in Medicare Part D and Medicare Advantage. For plan year 2026 and subsequent years, the cap will be the lesser of $35 or an amount equal to 25 percent of the maximum fair price established for the covered insulin product or an amount equal to 25 percent of the negotiated price of the covered insulin product. A copayment cap for insulin in private insurance plans was stripped.

NCPA continues to advocate for independent pharmacies throughout this process and will alert members as things evolve prior to expected final passage.