ARE MEDICARE’S NEGOTIATED PRICES FOR APIXABAN AND RIVAROXABAN CONSISTENT WITH VALUE BASED PRICES? EVIDENCE FROM A SYSTEMATIC REVIEW OF U.S. COST-EFFECTIVENESS ANALYSES
Author(s)
Joseph F. Levy, PhD, Isurujith Herath, MBBS, MPH, MBA, Nathan Jibat, MD, MPH, MBA, Jeromie Ballreich, MS, PhD.
Health Policy, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
Health Policy, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
OBJECTIVES: The Inflation Reduction Act authorizes Centers for Medicare and Medicaid Services (CMS) to negotiate Maximum Fair Prices (MFPs) for high-spending drugs but bars quality-adjusted life years and cost-effectiveness thresholds. We examined whether 2026 MFPs for apixaban (Eliquis) and rivaroxaban (Xarelto)—direct competitors in nonvalvular atrial fibrillation and the 1st and 3rd highest-spend drugs in the initial negotiation cohort—match value-based prices from published U.S. cost-effectiveness analyses for stroke prevention.
METHODS: We conducted a systematic review of U.S.-based cost-effectiveness analyses of apixaban and or rivaroxaban for NVAF stroke prevention available before the first Medicare drug price negotiation cycle. Eligible studies reported incremental costs and quality-adjusted life years versus warfarin, the standard comparator, because no head-to-head apixaban-rivaroxaban trials exist; evidence derives from ARISTOTLE and ROCKET-AF. For each study, we rebuilt a simplified model to isolate drug costs and calculated value-based prices at $50,000, $100,000, and $150,000 per QALY. We compared these distributions with estimated 2022 Medicare net prices and published 2026 MFPs, annualized from 30-day supply prices. Results used medians and interquartile ranges.
RESULTS: Fourteen U.S. cost-effectiveness evaluations met inclusion criteria. At a $100,000 threshold, the median annual value-based price was $5,119 for apixaban (IQR $4,207 to $6,135) and $4,066 for rivaroxaban (IQR $2,928 to $5,347). Estimated 2022 Medicare net prices of $3,708 and $3,132, respectively, fell within these ranges, indicating both drugs were already cost-effective prior to negotiation. The negotiated 2026 maximum fair prices of $2,810.5 for apixaban and $2,396.8 for rivaroxaban fell below median value-based prices at the $50,000 threshold.
CONCLUSIONS: Apixaban and rivaroxaban were already cost-effective at 2022 Medicare prices, and the negotiated 2026 MFPs further improved their cost-effectiveness. Although quality-adjusted life years were not used in negotiations, negotiated prices aligned with value-for-money assessments implied by existing economic evidence for these drugs.
METHODS: We conducted a systematic review of U.S.-based cost-effectiveness analyses of apixaban and or rivaroxaban for NVAF stroke prevention available before the first Medicare drug price negotiation cycle. Eligible studies reported incremental costs and quality-adjusted life years versus warfarin, the standard comparator, because no head-to-head apixaban-rivaroxaban trials exist; evidence derives from ARISTOTLE and ROCKET-AF. For each study, we rebuilt a simplified model to isolate drug costs and calculated value-based prices at $50,000, $100,000, and $150,000 per QALY. We compared these distributions with estimated 2022 Medicare net prices and published 2026 MFPs, annualized from 30-day supply prices. Results used medians and interquartile ranges.
RESULTS: Fourteen U.S. cost-effectiveness evaluations met inclusion criteria. At a $100,000 threshold, the median annual value-based price was $5,119 for apixaban (IQR $4,207 to $6,135) and $4,066 for rivaroxaban (IQR $2,928 to $5,347). Estimated 2022 Medicare net prices of $3,708 and $3,132, respectively, fell within these ranges, indicating both drugs were already cost-effective prior to negotiation. The negotiated 2026 maximum fair prices of $2,810.5 for apixaban and $2,396.8 for rivaroxaban fell below median value-based prices at the $50,000 threshold.
CONCLUSIONS: Apixaban and rivaroxaban were already cost-effective at 2022 Medicare prices, and the negotiated 2026 MFPs further improved their cost-effectiveness. Although quality-adjusted life years were not used in negotiations, negotiated prices aligned with value-for-money assessments implied by existing economic evidence for these drugs.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
EE425
Topic
Economic Evaluation
Topic Subcategory
Trial-Based Economic Evaluation
Disease
SDC: Cardiovascular Disorders (including MI, Stroke, Circulatory)