Impacted: Medicare Part D Clients

What you need to know

On Nov. 25, 2025, the Centers for Medicare & Medicaid Services (CMS) announced it has finalized negotiated prices for 15 high-cost Medicare Part D drugs, effective Jan. 1, 2027. The Maximum Fair Prices (MFPs) create discounts ranging from 38%-85% off the 2024 list price for medications for cancer, diabetes, respiratory conditions, and other chronic diseases. These 15 drugs accounted for $42.5 billion, or 15%, of 2024 Medicare Part D national spending. 

Overview 

The latest announcement brings the total number of negotiated drugs to 25 when combined with the 10 previously negotiated drugs with MFPs that are effective Jan. 1, 2026. Key highlights of the announcement include:  

• CMS savings estimates: Forty-four percent savings totaling $12 billion, as compared to 2024 spending net of rebates and certain fees and payments. $685 million in expected member out-of-pocket savings for 2027, based on a defined standard benefit design. 
• Glucagon-like peptide-1 (GLP-1) drugs included: Ozempic, Rybelsus and Wegovy are part of the negotiated drugs and will see a 71% discount on the 2024 list price.  

Prime’s position 

Prime Therapeutics (Prime) remains committed to delivering the lowest net cost options while navigating evolving market dynamics. We are prioritizing strategies for drug classes impacted by the Inflation Reduction Act (IRA) to ensure compliance and cost efficiency. In addition, our teams are actively monitoring generic launch timelines and evaluating opportunities for generic product swaps to optimize savings.

Next steps  

Prime will provide some of the details below at the Dec. 16, 2025 Medicare Center of Excellence (COE) meeting, while others will be addressed throughout the 2027 formulary development process. Additional information Prime will provide throughout this process includes: 

• A comparison of the CMS negotiated prices to Prime’s current negotiated prices. 
• Drug-level considerations impacting 2027 formulary development for each of the MFP drugs and their market baskets (e.g., drug pipeline, clinical considerations, competing manufacturers/drugs). 
• Estimated impact of negotiated prices to net plan liability for Prime book-of-business. 
• Evaluation of member out-of-pocket impact under typical enhanced benefit designs. For example, members enrolled in a copay benefit design may pay more due to “greater of” logic under Part D. 
• Clarity on Ozempic/Wegovy MFP price of $274 vs the Nov. 6, 2025 White House announcement of $245. 

There is no action needed by clients at this time. Prime will continue to provide updates as we learn more.

Questions

Reach out to your Prime account team representative.