Appeals Momentum: What Medicare’s Rx Price Talks Could Mean 💊⚖️
Quick scan: An appeals court upheld Medicare’s authority to negotiate prices on a select set of high-spend drugs — will that nudge your costs or just the news cycle? Let’s decode it without the legal headache 🧵✨
🔍 The Real Story
- A U.S. appeals court upheld Medicare’s ability to negotiate prices for a limited group of high-expenditure drugs, a key component of the Inflation Reduction Act’s Medicare changes. Further appeals are still possible, so this isn’t the final word.
- In practice, that means CMS can continue working toward a “Maximum Fair Price” for selected drugs rather than paying list price, pending any future court action.
- Source: Reuters coverage of the ruling (Aug 25, 2025): https://www.reuters.com/world/us/appeals-court-upholds-medicare-drug-price-negotiation-2025-08-25/
⚙️ What Changed
- Legally: The program cleared a major appellate hurdle, allowing implementation to continue for now. It could change if higher courts or new laws intervene.
- Operationally: CMS’s published timeline remains in effect unless a court says otherwise.
- CMS indicates negotiated prices begin with a first group of Part D drugs in 2026, with more drugs added across Part D and Part B in 2027–2028.
- Source: CMS overview of Medicare Drug Price Negotiation: https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation
- What’s next: Manufacturers may seek Supreme Court review. That’s a “may,” not a “will.” No one has a crystal gavel 🏛️
👩‍⚕️ What It Might Mean For You
- No mid-year surprises. Any changes tied to negotiated prices would show up in future plan years (think 2026 and beyond).
- If a drug you take is on the negotiated list:
- Your out-of-pocket could change based on your plan’s cost-sharing, formulary tier, and pharmacy network. Results vary by plan and contract.
- Plans may adjust tiers or preferred pharmacies — or keep them as-is. It’s plan-specific.
- If your meds aren’t on the list: You may see indirect effects (like plan bids, premiums, or formularies), but those vary and are not guaranteed.
- Bottom line: Lower pharmacy costs are possible over time, but your actual costs depend on your plan details and formulary decisions. Keep an eye on your Annual Notice of Change (ANOC) this fall đź‘€
đź’Ľ Broker Notes
- Lead with curiosity, not certainty. Avoid promising savings; rely on ANOC/EOC and official formularies.
- Watch for:
- 2026 formularies and tiering for any negotiated drugs
- Utilization management updates such as prior authorization (PA), step therapy (ST), and quantity limits (QL)
- Crosswalks if any plans consolidate or exit
- Prep your reviews:
- Keep an accurate med list with dose/frequency
- Check plan pharmacy networks and any 90-day or mail options
- Coordinate with prescribers if a formulary shift prompts alternatives
- Compliance check: No superlatives, no “lowest cost” promises, no guaranteed results. Educate, compare, document ✅
đź“ť Action Steps
- If you’re on Medicare:
- Make an updated list of your meds before AEP (Oct 15–Dec 7).
- Read your ANOC and Evidence of Coverage when they arrive.
- During plan comparisons, ask: Is my drug on the negotiated list? What tier is it on? Which in-network pharmacy offers the best cost-sharing for me?
- If you’re helping others:
- Use carrier producer portals for 2026 formulary lookups.
- Bookmark CMS’s negotiation timeline for quick client education.
- Flag clients on potential negotiated drugs for early fall check-ins.
đź”— Sources
- Reuters: U.S. appeals court upholds Medicare drug price negotiation program (Aug 25, 2025): https://www.reuters.com/world/us/appeals-court-upholds-medicare-drug-price-negotiation-2025-08-25/
- CMS overview of Medicare Drug Price Negotiation: https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation
The Marketplace Hotline is a marketing platform and not a government program. We connect individuals and brokers with licensed insurance professionals. We are not connected with or endorsed by the U.S. Government or the federal Medicare program. This content is educational, not legal advice.