Sponsors (3)
The bill reduces out-of-pocket coinsurance for many Medicare Part D enrollees and increases pricing transparency, but risks cost-shifting by plans, uneven benefits due to exemptions, and temporary mispricing from reliance on prior-year reports.
Medicare Part D enrollees will pay lower coinsurance when a plan's negotiated net price is below the wholesale acquisition cost (WAC), reducing out-of-pocket spending between the deductible and the out-of-pocket threshold.
People with chronic conditions who rely on specialty or high-cost drugs will generally face smaller cost-sharing for medications subject to coinsurance, improving medication affordability and likely supporting better adherence.
Aligning patient cost-sharing with plan sponsors' reported net prices increases pricing transparency and makes coinsurance more reflective of true market prices.
Plan sponsors may offset lost revenue by raising copayments, narrowing formularies, or altering benefit designs, which could increase costs or reduce access for some enrollees.
Because certain drugs are exempted under existing statutory paragraphs, not all beneficiaries or medications will see lower coinsurance, producing uneven benefits across enrollees and therapies.
Insurers must use prior-year Detailed DIR Reports to set current coinsurance, which can delay recognition of recent price changes and lead to temporarily mispriced patient cost-sharing.
Based on analysis of 2 sections of legislative text.
Introduced February 12, 2025 by Don Davis · Last progress February 12, 2025
Requires Medicare Part D plans, for plan years beginning January 1, 2026, to calculate coinsurance for covered drugs (when plans use coinsurance rather than copayments and for amounts between the deductible and the out-of-pocket threshold) using the drug’s actual acquisition cost—the plan’s negotiated net price reported on the prior year’s Detailed DIR Report—whenever that price is lower than the wholesale acquisition cost. Adds a statutory definition of “actual acquisition cost” consistent with current federal regulations and makes a conforming coverage reference.