This information was sent to me by the National Community Pharmacists Assoc – which represents independent pharmacists and I have been a member for FORTY YEARS.
There is a lot of FUTURE DATES when some of these “savings” will start… Whoever is sworn in as our President in Jan, 2025 will get to deal with the good or bad as these new rules “kick in”. Likewise, a lot of small businesses – like your local independent pharmacy will get new taxes so that a TAX BREAK to private equity investors – you know those “fat cats” that have 100’s of billions of dollars to trade in the stock market.
Medicare/Medicaid folks could have their medications no longer covered because the pharma no longer wishes to have one or more of their medications covered by Medicare/Medicaid. Everyone should notice that there is no mention of the insurance/PBM industry agreeing to any price negotiations The top 4-5 PBM’s are owned by insurance companies and I have seen stated numerous times that the PBM demand up to a 75% discount/rebate/kickback for the pharma to have one or more of their meds on the PBM’s pre-approved formulary, otherwise the pharma’s meds would ALWAYS REQUIRE a prior authorization to get the PBM to approve coverage for the medication that the pt’s prescriber considered was in the pt’s best interest. These same small number of PBM’s control the price and coverage of 80%-90% of the FOUR BILLION PRESCRIPTIONS we fill every year… including those Rxs handled by those “cash Rx discount cards” Since mid-term election is abt 3 months away… I wonder how much money the Insurance/PBM industry contributed to the re-election campaigns of those who voted for the INFLATION REDUCTION ACT ?
everyone should read the CBO’s opinion of the fiscal outcome of this act https://nypost.com/2022/08/15/inflation-reduction-act-will-cost-middle-class-20b-cbo/
NCPA Member Summary of the Inflation Reduction Act
On Aug. 16, 2022, President Biden signed the Inflation Reduction Act, which includes provisions that should impact
community pharmacy. For a thorough analysis, see Kaiser Family Foundation’s (KFF) slides and presentation.
Medicare Drug Price Negotiation. For pharmacies, reimbursement could be impacted under the new Medicare 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 has secured language for the record in the House of Representatives that the
Centers for Medicare & Medicaid Services (CMS) will not implement the act in a way that would cause any reduction in
pharmacy reimbursement or require or permit price concessions or other remuneration from the pharmacy because of
Medicare drug price negotiation. Additionally, the language stated that implementation should operate in the same
manner as the Medicare Part D Coverage Gap Discount Program.
Starting in 2026, the secretary of the Department of Health and Human Services will 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:
• 2026: 10 drugs based on Part D spending
• 2027: 15 drugs based on Part D spending
• 2028: 15 drugs based on combined Part D and Part B spending
• 2029 and beyond: 20 drugs based on combined Part D and Part B spending
The above is a cumulative list and should result in 60 negotiated drugs by the end of the decade. According to Juliette
Cubanski, deputy director of the program on Medicare policy at KFF, CMS should know in 2023 the list of drugs for 2026.
Manufacturers who do not negotiate will face an excise tax, starting at 65 percent of a drug’s prior year sales, increasing
by 10 percent every quarter up to 95 percent. The tax would be suspended if manufacturers choose to have their drugs
no longer covered by Medicare or Medicaid. Additionally, manufacturers face a civil monetary penalty for not offering
the negotiated price of up to 10 times the difference between the price charged and the negotiated price.
Annual out–of–pocket cap. The 5 percent coinsurance for catastrophic coverage in Medicare Part D is eliminated in
2024. 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.
Optional “smoothing” of patient cost–sharing. Starting in 2025, Part D patients can elect to have cost–sharing smoothed
out over the course of the benefit year. The growth in Part D premiums is capped at 6 percent per year from 2024 to
2030.
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.
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.
Drug rebates. For each calendar quarter beginning on or after January 1, 2023, drug manufacturers must pay a rebate if
drug prices increase faster than the rate of inflation for:
• Single–source drugs and biologicals covered under Medicare Part B, except those whose average annual cost is
less than $100; and
• All covered drugs under Medicare Part D, except those where average annual cost is less than $100.
Insulin. Monthly copayment spend on insulin is capped at $35 for plan years 2023, 2024, and 2025 for those drugs
covered 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. Insulin furnished through durable medical equipment under Medicare Part B will
also have a monthly copayment cap at $35, with no deductible, beginning in 2023. Currently, Medicare Part D’s Senior
Savings Model has a $35 maximum copayment for insulin. According to the National Conference of State Legislatures, at
least 21 states have enacted state legislation capping insulin copayments.
Tax provisions. NCPA joined in a sign–on letter to leadership expressing concerns about the law’s tax provisions. The law
gives the Internal Revenue Service an additional $80 billion in funding to grow the IRS from 80,000 to over 160,000
employees. Additionally, an amendment added last minute by the Senate extends for two years the Section 461(l) cap
on losses business owners can claim. This $52 billion tax hike on pass–through businesses was used to offset the cost of
exempting private equity investors from the 15–percent corporate minimum tax.
Filed under: General Problems
Leave a Reply