OBJECTIVES: By September 1, 2023, CMS will announce the first 10 Medicare Part D drugs selected for the Drug Price Negotiation Program. “Maximum fair prices” negotiated for these highest-expenditure drugs will go into effect in 2026. As a sneak peek at what may happen, this analysis used Medicare claims data to rank and predict the drugs that CMS may target.

METHODS: Administrative claims data from the Merative™ MarketScan® Medicare Database (comprising enrollees in employer-sponsored Medicare Supplemental and Advantage plans) during the latest one-year period of available data (10/1/2020–9/30/2021) were analyzed using the Treatment Pathways tool. First, total expenditures on Part D drugs were calculated using the sum total payments in patient claims, also recording the number of users of each drug. After applying waiver and exception criteria CMS intends to use in the selection process, a list of 20 drugs was formed and ranked in order by highest total expenditure in the time period, with the first 10 drugs deemed most likely to be targeted by CMS and the remaining 10 drugs the “runners-up.”

RESULTS: Of the 20 drugs identified, apixaban had the highest expenditures, totaling $245 million (n=59,828 users). The next highest was adalimumab with $112 million (n=1,816 users). The following medications completed the top 10 list (ranked highest to lowest expenditures): rivaroxaban, dulaglutide, sitagliptin, ibrutinib, enzalutamide, empagliflozin, etanercept, and tiotropium bromide. These medications were typically indicated for common chronic conditions. Ibrutinib, enzalutamide, and etanercept had less than 1,000 users each but high mean per-user payments ($129,829, $84,200, and $56,384, respectively).

CONCLUSIONS: These cost analyses support price negotiation planning initiatives by drug manufacturers likely to be affected by CMS’s initial target list. Medicare Advantage and Supplemental plan enrollees represent a subset of all Medicare patients and future comparisons of drug spending before and after CMS price controls will benefit from this preliminary evidence.