CMS yesterday announced a proposed rule for Medicare Part D for contract year 2026. There’s a lot to get through, but here’s what we can tell you now:
The rule (linked here) addresses many concerns we have shared with CMS over the years about the one-sided nature of PBM Part D contracts. However, it leaves many holes. NCPA recently asked CMS for contracting guardrails in the Part D program (see here) and we are pleased that this proposed rule would allow pharmacies in limited circumstances to terminate a Part D contract or participation in a particular network without cause. We also applaud CMS for requiring Part D sponsors/PBMs to notify pharmacies which plans the pharmacies will be in-network for in a given plan year by Oct. 1 of the year prior to that plan year. That provision is the result of a direct ask from NCPA.
However, we are concerned by other proposals that would require plan sponsors/PBMs to include in their pharmacy contracts a requirement for pharmacies to be enrolled in the Inflation Reduction Act Medicare Drug Price Negotiation Program Medicare Transaction Facilitator Data Module. As we made clear to CMS months ago, mandatory participation in the program will almost certainly force pharmacies to take substantial losses. PBMs currently reimburse pharmacies far below their cost to dispense those very same drugs. Pharmacies that are forced to lose money in the program, while waiting endless days for manufacturer refunds, will be unable to participate, and that will restrict access for patients. You can see NCPA’s most recent talking points on the IRA program that starts in 2026 here.
Overall, it is encouraging that the proposed rule reflects many of the conversations we have had with CMS officials over the years. We have worked hard to educate them on how unfair PBM practices can jeopardize patient access. There is more work to be done, however, and we will keep fighting. In the meantime, we will continue analyzing this important rule and we will share our concerns with CMS in our comments by the Jan. 27, 2025 deadline. We will also keep you up to date in the coming weeks.
