not used title
not used title
Misaligned incentives in Medicare Part D are increasing costs for seniors with diabetes. While insurers negotiate larger and larger rebates with biopharmaceutical companies each year, seniors continue to pay cost sharing based on the pre-rebated price of their diabetes medicine, rather than the lower negotiated rates.
New research by Milliman demonstrates that rebate growth has created a steadily widening gap in the share of total costs paid by Part D beneficiaries on a gross vs. net basis (i.e., before and after rebates are factored in). Part D is structured so that non-low-income beneficiaries pay an average of 25 percent of their pre-rebated medicine costs in the initial coverage phase and coverage gap as of 2020. However, Milliman finds that after rebates, seniors using insulin will pay an average of 46 percent of their medicine costs in the initial coverage phase and 47 percent in the coverage gap in 2020.
If we don’t reform the rebate system in Part D, diabetes patients could soon pay twice what their insulin and other medications costs to the health plan (the net cost after rebates) when they are in the deductible. In 2008, these beneficiaries paid 106 percent of their net medicine costs in the deductible, but by 2026, that number is projected to almost double to 201 percent. Why should diabetes patients pay twice as much as their insurer for their insulin.
Last fall, the Department of Health and Human Services Office of the Inspector General proposed a regulation encouraging the rebates Part D plans negotiate with biopharmaceutical companies to be entirely passed through to beneficiaries at the pharmacy counter. An analysis by Avalere Health shows that if rebates were used to lower patient costs, a Part D beneficiary taking five medicines, including insulin, could see their annual out-of-pocket spending decrease by $962. Their annual premium could increase by $67, which would result in a total savings of $895. The proposed rule could finally bring down costs for seniors suffering from chronic illnesses.
Learn more about the right solutions to fix Medicare at PrescriptionForMedicare.org.
Holly Campbell
Holly Campbell is former deputy vice president of public affairs at PhRMA focusing on the cost and value of medicines.
Holly Campbell
Author Twitter
Author LinkedIn
What AARP isn’t telling seniors about MFN
August 24, 2026
CMS proposal could discourage patient-centered innovation
August 18, 2026
Nearly 1 in 4 patients initially denied access to IRA medicines
August 6, 2026
Medicare Part D at 20: Building on a strong foundation
July 23, 2026
MFN won’t lower costs when insurers call the shots
May 8, 2026
Guest Blog: How MFN price controls could decide my health care
April 30, 2026
States should avoid repeating the IRA’s price‑setting mistakes
April 21, 2026
Insurers routinely block seniors’ access to medicines in Medicare Part D
March 18, 2026
MFN undermines U.S. biopharmaceutical innovation
February 25, 2026
CMS puts patients and innovation at risk with MFN
February 24, 2026
New list of selected drugs highlights growing consequences of government price setting
January 28, 2026
Guest blog: Making the most of the Medicare Prescription Payment Plan
December 8, 2025
The IRA’s price setting doesn’t guarantee lower costs or better access
November 17, 2025
What seniors can expect this open enrollment
October 14, 2025
Part D premiums are going up, while choices are going down
October 8, 2025
Delivering breakthroughs and lower costs for patients
September 8, 2025
Celebrating 60 Years of Medicare
July 30, 2025
Medicare patients face higher drug costs, despite IRA promises
July 22, 2025
Medicare Part D plans initially denied medicines for more than 70% of patients in four chronic disease areas
June 16, 2025
PBMs launch new ad campaign to block reforms
May 5, 2025
CMS, don’t fall behind the rest of the medical community on obesity
February 14, 2025
Patients are losing as government price setting continues
January 17, 2025
A new administration poses new opportunities for patient access
December 17, 2024
Reimagining patient access through meaningful policy reform
November 5, 2024
CMS needs to do better
November 4, 2024
New PES survey: Out-of-pocket costs lead key health care priorities ahead of the November election
October 30, 2024
Is CMS paying attention to the growing access barriers for Medicare patients under the IRA?
October 18, 2024
Did the administration consider the importance of blood cancer medicines to patients in price setting process?
October 8, 2024
Did the administration consider the importance of blood clot medicines to patients in the price setting process?
September 25, 2024
The Inflation Reduction Act could increase costs and reduce access for millions of seniors
September 17, 2024
Are the IRA’s Part B inflation rebates lowering costs for Medicare patients? No.
September 16, 2024
Did the administration consider the value of innovative diabetes medicines in price setting process?
August 28, 2024
New survey: Insurers confirm IRA will reduce patient treatment options
August 20, 2024
The unintended consequences of government price setting in Medicare Part D
August 16, 2024
Don’t put the government between patients and their medicines
August 7, 2024
What is the low-income subsidy program and how is it changing?
July 31, 2024
Case study: How seniors could face access disruptions because of the IRA’s price setting provisions
July 22, 2024
PhRMA reiterates concerns with IRA price setting program, urges CMS to mitigate harm
July 3, 2024
The IRA could lead to higher out-of-pocket costs for 3.5 million Medicare patients in 2026
June 25, 2024
Ongoing federal probes shed light on PBM and insurer practices
May 20, 2024
WTAS: The consequences of consolidation and vertical integration
May 6, 2024
IRA is already negatively impacting access to medicines in Part D
April 25, 2024
Insurance data: PBM reform has no material impact on premiums
April 24, 2024
New study finds insurers and PBMs increasing access restrictions in Medicare Part D
April 16, 2024
Four years later, Maryland board still hasn’t delivered for patients
February 12, 2024
Setting the Record Straight: Comparing U.S. drug prices to those in foreign countries hurts patients
February 7, 2024
As the administration continues to falsely claim Medicare “negotiation,” keep these points in mind
February 1, 2024
ICYMI: When middlemen get in the way, it’s the patients who lose
December 5, 2023
ICYMI: WSJ — Same Drug, Two Prices: Why the Higher Price Prevails
November 15, 2023
ICYMI: 3 takeaways on the IRA’s unintended consequences from America’s Physician Groups’ 2023 annual fall conference
November 6, 2023
One year to Election Day: Four voter priorities to watch
November 6, 2023
ICYMI: Scott LaGanga and Matt Salo deliver a State of the Industry Report
October 25, 2023
ICYMI: Government watchdog report finds patients in Medicare Part D paid billions more for medicines than insurers and PBMs
September 28, 2023
IRA threatens seniors’ access to robust treatment options
September 26, 2023
Medicare Prescription Payment Plan will benefit patients if implemented correctly
September 21, 2023
Correcting the record: IRA’s government price setting provisions are unconstitutional
September 8, 2023
New PhRMA ad exposes yet another way PBMs get between patients and their medicines
September 5, 2023
IRA changes to Part D risk access to medicines
August 24, 2023
With the first list of medicines out, let’s not forget why government price setting is bad policy
August 22, 2023
One year later IRAs unintended consequences are becoming reality
August 16, 2023
AARP’s latest misleading report
August 11, 2023
Three things to know from the latest Patient Experience Survey
July 20, 2023
Four things for CMS to keep in mind as they implement changes to Part D
June 7, 2023
ICYMI: PBM exec admits choosing profits over patients
June 2, 2023
4 key facts on medicine prices and spending
May 9, 2023
4 Things to know about PhRMA’s new 50-state poll
May 4, 2023
Americans want state policymakers to lower out-of-pocket costs
May 1, 2023
Three facts about health care spending
April 25, 2023
CMS guidance on IRA price setting process doubles down on bad policy
April 14, 2023
A guide to MedPAC’s Part B vote today
April 13, 2023
MedPAC proposal threatens access to medicines in Part B
April 6, 2023
States can support access to medicine as COVID-19 Public Health Emergency ends
April 5, 2023
Arkansas puts patients first with new share the savings law
April 4, 2023
CMS coverage policy is detrimental to Alzheimer’s patients
April 4, 2023
How Part B’s ASP system helps control costs for the government and seniors
March 30, 2023
Key Trends: Patient experience data reveal how insurers and middlemen impose barriers in health care
March 29, 2023
Medicare Part B spending in four points
March 28, 2023
Holding pharmacy benefit managers accountable
February 23, 2023
Stopping pharmacy benefit managers from “gaming the system”
February 22, 2023
Senate hearing to examine bipartisan reforms to rein in middlemen
February 16, 2023
Minnesota lawmakers are letting PBMs off the hook, and threatening patients’ access to medicines
January 31, 2023
ICYMI: PhRMA kicks off the year at the 2023 J.P. Morgan Health Care Conference
January 19, 2023
In their own words: Financial barriers exacerbate access challenges for insured Americans
December 8, 2022
Putting Delaware patients first: Protecting Patient Assistance Programs
November 22, 2022
Medicare Part D open enrollment and what recent changes mean for beneficiaries
November 17, 2022
New data show how insurers and middlemen shift Rx costs onto patients
November 16, 2022
In their own words: Insured Americans struggle to navigate complex coverage
October 26, 2022
Many seniors are paying more for Part D medicines than their insurer
October 18, 2022
New comments outline ways to protect patients from health plans and PBMs who profit from patient assistance
October 7, 2022
Busting 3 Myths About Copay Coupons
October 5, 2022
Mental Illness Awareness Week – A time for reflection
October 3, 2022
A key fact the White House is reluctant to admit
September 27, 2022
A key fact the White House is reluctant to admit
September 27, 2022
Navigating the patient experience: Burdens and barriers standing between patients and their care
September 12, 2022
CMS coverage policies restrict patient access to important treatment options for Alzheimer’s disease
September 1, 2022
Making coupons count for patients at the pharmacy counter
August 25, 2022
Making coupons count for patients with HIV
August 8, 2022
Myth vs. Fact: The Senate’s latest price setting proposal
August 5, 2022
The Senate’s latest price setting proposal will undermine U.S. economic growth
August 3, 2022
Celebrating Medicare’s 57th anniversary
August 2, 2022
The Senate’s latest price setting proposal will undermine: Our health care system
July 28, 2022
The Senate’s latest price setting proposal will undermine: Patient access to medicines
July 26, 2022
Survey Says: Prescription drug prices are not fueling inflation concerns for Americans
July 22, 2022
New research shows competition driven by biosimilars helps control costs in Part B
July 19, 2022
Putting patients first at the state level — A conversation with Mark Reisenauer, President of Astellas Pharma US
July 14, 2022
Polling continues to show voters reject so-called Medicare “negotiation” once they learn about consequences for patients
July 12, 2022
Patients win as West Virginia implements first-in-nation share the savings policy
July 8, 2022
3 things voters are concerned about when it comes to their health care coverage
July 7, 2022
Copay assistance is a lifeline for patients. So why are insurers blocking it?
June 29, 2022
CMS coverage decision restricts access to treatments for Alzheimer’s disease
June 22, 2022
Patients support state action requiring PBMs and insurers to share savings and cap costs for medicines
June 16, 2022
New poll shows voters sounding the alarm on health insurance companies and PBMs
June 6, 2022
PhRMA warns of the growing influence of middlemen over patient access and out-of-pocket costs for patients
May 31, 2022
ICYMI: PhRMA COO Lori Reilly spotlights efforts to improve health care in 2022 and beyond
May 9, 2022
Annual projections from NHE compared to actual health care spending
May 5, 2022
Study finds insurance barriers disproportionately burden patients with chronic illness
May 4, 2022
Three charts show how the Medicare Part D program could be improved to work better for seniors and people with disabilities
April 27, 2022
What’s really happening when it comes to prescription drug costs
April 27, 2022
Part D 101: Three charts show how the program provides comprehensive prescription drug coverage
April 26, 2022
5 public opinion polling trends to watch
April 22, 2022
Analysis: States can help patients save nearly $1,000 annually on their medicines
April 21, 2022
New analysis confirms hospitals markup prices for oncology therapies
April 21, 2022
How standardized plans can improve patients’ access to medicines
April 18, 2022
The patient experience: Uncovering the barriers to care for insured Americans
March 28, 2022
Correcting the record: Putting medicine costs and spending in context
March 24, 2022
Sharing rebates can save Americans with diabetes 500 each year and improve adherence
March 16, 2022
If drug prices are growing below the rate of inflation, why are patients still feeling the sting at the pharmacy?
March 8, 2022
The patient experience: Insurance barriers continue to impede access to health care, especially among the country’s underserved
February 28, 2022
Government price setting leaves behind families counting on new medicines
February 23, 2022
Part B 101: Three charts show the program helps control costs for health care system and enrollees
February 18, 2022
PhRMA submits comments urging CMS to withdraw coverage proposal
February 11, 2022
Medicaid 101: Three charts on access and spending
February 3, 2022
Government price setting won’t stop insurers from shifting costs to patients
February 2, 2022
Research and development continues long after a medicine is initially approved
February 1, 2022
New comments outline ways to counteract cost-shifting insurance trends
January 28, 2022
Patients need to pay less for their medicines. States can help.
January 26, 2022
It’s a new year, but sadly Congress is still pursuing flawed price setting policies
January 25, 2022
New poll of all 50 states and 435 Congressional Districts shows perils of so-called Medicare “negotiation”
January 25, 2022
New study finds more than half of brand medicine spending goes to the supply chain and others
January 7, 2022
Post-approval research save lives. Why is Congress trying disincentivize it?
December 17, 2021
A price control by any other name would still put patients at risk and threaten innovation
December 9, 2021
Making medicines more affordable: Making insurance work like insurance
December 8, 2021
3 things to know about the importance of post-approval research and development
December 6, 2021
New data show insurers and PBMs increase barriers to care
December 2, 2021
Guest post: Congress should not put future innovation at risk
November 29, 2021
Insurance design barriers can impact patient adherence and can lead to poor health outcomes
November 23, 2021
What is missing in the current drug pricing plan
November 23, 2021
ICYMI: PhRMA CEO speaks at STAT Summit about government price setting
November 19, 2021
Making medicines more affordable: Sharing savings at the pharmacy counter
November 19, 2021
Three things to know about so-called Medicare negotiation polling
November 18, 2021
In the current health care debate, Congress has lost sight of what matters to U.S. voters
November 15, 2021
Making medicines more affordable: Modernizing Medicare
November 11, 2021
Making Medicines More Affordable: Making coupons count
November 5, 2021
What they are saying: Government price setting for medicines is not the answer
November 4, 2021
Four things to know from IQVIAs latest report
October 29, 2021
The patient experience: Insurance design hurdles lead to access issues for too many Americans
October 28, 2021
CMS finds medication adherence saved Medicare up to 46.6B in avoided health care costs between 2013 and 2018
October 19, 2021
The patient experience: Out-of-pocket costs are driving patients affordability and access challenges
October 19, 2021
ICYMI: New study confirms policies like H.R. 3 could significantly reduce drug development
October 18, 2021
New poll shows Americans reject Medicare negotiation once they learn more about the policy
October 15, 2021
What is Kaiser Family Foundation up to?
October 12, 2021
New report shows 3 in 10 Americans that have insurance still face a financial barrier to care
October 7, 2021
Industry leaders discuss the impact of the drug pricing debate
September 23, 2021
Five reasons tying VA prices to Medicare Part D misses the mark
September 22, 2021
America’s biopharmaceutical companies to Congress: Government “negotiation” is the wrong approach
September 15, 2021
Recent polling misrepresents public support for Medicare “negotiation”
August 31, 2021
What they’re saying: Patient advocates want to protect Medicare from government interference
August 24, 2021
Myth vs. fact: Polling and Medicare “negotiation”
August 12, 2021
ICYMI: Event spotlights how we can make Medicare work better for patients
August 4, 2021
The future of the rebate rule: Will policymakers stand with patients?
August 2, 2021
Celebrating Medicare’s 56th anniversary
July 30, 2021
Government “negotiation” could have devastating consequences for Medicare enrollees
July 23, 2021
Protecting Medicare from government interference
July 21, 2021
3 factors impacting medication adherence for patients with diabetes
July 20, 2021
Data shows voters strongly support protecting access to their medicines
July 15, 2021
Medicare “negotiation” proposals threaten Americans’ access to medicines
June 30, 2021
New reports shed light on key facts about medicines and affordability
June 8, 2021
Out-of-pocket trends in Medicare Part D show rising costs for seniors
May 24, 2021
Study finds nearly half of payers believe innovative contracts can lead to lower patient out-of-pocket costs
May 17, 2021
The ABCs (and Ds) of Medicare
May 13, 2021
New data from insurers show detriments of copay accumulator adjustment programs
April 28, 2021
West Virginia becomes the first state to lower patient costs by sharing the savings
April 20, 2021
ICYMI: Bipartisan lawmakers urge new administration to oppose changes to six protected classes policy
March 11, 2021
Nearly 40% of commercially insured patients face half their annual out-of-pocket expenses from just one health care encounter
March 2, 2021
Key excerpts: PhRMA submits comments to keep the six protected classes protected
February 19, 2021
Top five issues voters want addressed in the administration’s first 100 days
February 18, 2021
Action needed to preserve the six protected classes
February 3, 2021
Insurers shift medicine costs to patients with severe chronic illnesses
February 1, 2021
The latest misleading “poll” on drug pricing
January 28, 2021
The new Administration should reconsider a recent HHS rule that could negatively impact patient access and affordability
January 27, 2021
Election insights: Common ground areas to address Americans’ health care concerns
January 26, 2021
New insulin report highlights how incentives benefit middlemen, harm patients
January 22, 2021
Key facts: The final rebate rule will be a positive change for patients
January 19, 2021
New data show retail medicine prices fell in 2019
January 13, 2021
End of year Part D reading List
December 18, 2020
Election insights: Voter priorities in the states
December 17, 2020