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Drug Channels
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Expert insights on pharmaceutical economics and the drug distribution system.
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A manufacturer’s list price and refund method could determine whether a pharmacy stocks an MFP drug.
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Under the Part D Maximum Fair Price (MFP) process, the manufacturer’s refund method can change the economics of a MFP drug at the pharmacy.
The pharmacy may acquire a drug near its wholesale acquisition price (WAC), then be reimbursed at the lower MFP plus a dispensing fee.
The pharmacy would have to carry the debt until the manufacturer’s refund arrives.
In a Milliman example from a recent white paper, a pharmacy buys a MFP drug for $10,000 and receives $6,000 at the point of sale. That leaves about $4,000 tied up (per MFP drug dispensed) while the pharmacy waits for the refund.
---
The refund benchmark matters, too.
With the Standard Default Refund Amount, the manufacturer refunds the difference between WAC and MFP.
For a community pharmacy whose prior reimbursement was below WAC, this can let the pharmacy retain its acquisition discount. We break down that math in this blog 👉🏻 https://t.co/sHLNuFAO86
A contract price refund is based on what the pharmacy actually paid. Where the pharmacy’s prior margin depended on that acquisition discount, this approach can compress the margin until it's essentially just the dispensing fee.
---
Timing of payment can also become an issue--NCPA found 67% of pharmacies waited more than 22 days for manufacturer refunds, and about 22% waited more than 28 days.
So the stocking decision is about more than the final margin. It also depends on how much cash the pharmacy must carry and how long it waits to get paid.
You can see how a pharmacy with moderate MFP volume could have cash flow issues if (using the Milliman hypothetical example from the paper) each claim requires an extra $4,000 of cash flow/credit line.
Lowering the WAC helps address this issue for pharmacies, which is another of the pressures pushing towards a Net Pricing Drug Channel #NPDC
Federal policy is moving quickly. How will the drug channel respond?
From IRA implementation and Medicare pricing changes to Part D reform and most-favored-nation (MFN) concepts, federal actions are influencing manufacturer strategy, channel economics, and patient access.
On Tuesday, March 16, “From Policy to Practice: How Federal Reform Is Reshaping the Drug Channel” at the 2027 Drug Channels Leadership Forum will explore what these changes mean in practice and where their biggest effects could emerge.
Meet The Panelists
▪️ Joel White, Head of Health Practice | Monument Advocacy
▪️ Conor Sheehey, MA, Director | Leavitt Partners
▪️ Rena Conti, Professor | Boston University Questrom School of Business, Department of Markets, Public Policy and Law
Moderated by Jennifer Snow, MPH, Founder | Apteka
📅 March 15–17, 2027
📍 JW Marriott Miami Turnberry Resort & Spa
Request your invitation to take part in the conversation: https://t.co/RRpnQjZhoe
Invitation only. No press. No recordings.
#DCLF2027 #DrugChannels #HealthPolicy #DrugPricing
Lower drug spending for an employer doesn’t necessarily mean lower costs for its employees.
An employer can save while patients pay more.
---
In the latest Drug Channels article, we examine how pharmacy benefit design divides costs and savings between employers and patients, using data from KFF’s 2026 Employer Health Benefits Survey.
A few findings to spike your interest:
🔹 71% of workers in non-HSA-qualified plans have four or more drug benefit tiers, compared with 41% in HSA-qualified plans.
🔹 Among workers in plans with at least three tiers, 52% in HSA-qualified plans face coinsurance for preferred drugs, compared with 15% in non-HSA-qualified plans.
🔹 Coinsurance is generally calculated using a drug’s negotiated price before manufacturer rebates. Those rebates can reduce an employer’s net cost without reducing what the patient pays at the pharmacy.
---
The number of tiers doesn't say much about what happens to the patient.
Deductibles, premiums, employer contributions, out-of-pocket limits, and the medications a patient needs all matter when comparing plans.
For employers: How much of reported savings come from a lower drug cost, and how much come from a higher patient contribution?
Read the full analysis.
👇🏻
The State of Employer Pharmacy Benefits in 2026: When Plan Savings Come From Higher Patient Costs
https://t.co/PdsW6peomF
The U.S. doesn’t have one health insurance system.
It has a patchwork of public programs and private plans.
Plus millions still uninsured.
---
According to the U.S. Census Bureau:
🔵 65.7% had private coverage at some point during the year.
🔵 35.8% had public coverage, including Medicare and Medicaid.
🔴 7.9% (26.7 million people) were uninsured for the entire year.
(Note: The coverage categories overlap because people can have more than one type of coverage during the year)
Employment-based coverage was the largest source of insurance, covering 53.5% of the population.
---
Even among people with private insurance, the patient experience can look very different.
↳ Deductibles, copayments, coinsurance, drug coverage, and pharmacy networks vary across plans.
So knowing how many people have coverage is just a starting point. The details of that coverage are also important, particularly as coverage has been becoming less rich due to rising costs. More on that in the blog tomorrow 😉
Are you surprised we still had ~27 million people uninsured last year?
Who to follow
Drug Topics
@Drug_Topics
Since 1857, we've been reporting on issues important to retail, community and health systems pharmacists. We proudly serve 155,000 readers.
Antonio Ciaccia
@A_Ciaccia
Advocate for drug price transparency, competitive healthcare markets, & patient-centered care @46brooklyndata @3AxisAdvisors. Dad to Franco, Marco, Vera, Enzo.
PCMA
@pcmanet
PCMA is the national association representing America’s pharmacy benefit managers (PBMs). PBMs are working every day to secure savings, enable better health out
CMS just finalized a policy that could make Medicare drug negotiations more effective.
It could also make follow-on innovation less attractive.
---
CMS finalized the rules for the next phase of Medicare drug price negotiation.
The rule establishes policies for 2029 and beyond, including:
↳ How CMS selects and negotiates prices for Part B and Part D drugs.
↳ A temporary price floor for certain small biotech drugs.
↳ Part D formulary and payment requirements for selected drugs.
There’s far too much in this final rule (695 pages) to cover with any depth in a LinkedIn post, but one provision could have major implications for drug spending and future innovation.
---
CMS will treat certain new formulations as part of the original drug for negotiation purposes, even when an added ingredient enables a different route of administration.
For example, Keytruda and Keytruda Qlex (subcutaneous formulation). Merck says it is targeting 30% to 40% U.S. adoption of Qlex by the end of 2027.
Assuming the rule remains in place, if CMS selects Keytruda and includes Qlex in the selected drug, the negotiated maximum fair price would apply across both formulations. Medicare Part B payment for covered Qlex would be based on that price during the applicable period.
---
That creates a tradeoff:
🏭 Manufacturers may have less incentive to invest in follow-on innovations, such as more convenient dosage forms.
💵 Negotiation can also reduce Medicare drug spending across more utilization, including patients who switch to the new formulation.
The result is a more effective negotiation program at lowering spending, and at the same time a different set of incentives for developing improvements to existing medicines.
What do you think about the decision to include all formulations as part of the selected drug under the IRA?
🔗 Source: CMS Medicare Drug Price Negotiation Program and Medicare Prescription Drug Benefit Program Final Rule (also includes the full final rule at the bottom): https://t.co/t0n6bAiBNK
PBM customers rated their PBM as more transparent on almost everything this year compared to 2025.
Except one category: sources of revenue.
---
A new PSG customer satisfaction survey asked PBM customers to rate their PBM's transparency across six areas on a 1-5 scale. Every category ticked up from 2025 to 2026, except one:
📊 Access to data: 3.5, up from 3.3
📊 Formulary strategies: 3.5, up from 3.3
📊 Utilization management strategies: 3.5, up from 3.4
📊 Audit rights: 3.4, up from 3.2
📊 Rebates (paid and excluded): 3.2, up from 3.1
📊 Sources of revenue: 2.7, unchanged from 2025, and the lowest-rated category by a wide margin
20% of respondents rated their PBM as not at all transparent related to sources of revenue.
Customers of non-Big 3 PBMs rated their PBM meaningfully more transparent than Big 3 customers on every one of the six items, with the widest gaps on sources of revenue (3.2 vs. 2.5) and formulary strategies (3.8 vs. 3.2).
---
Plan sponsors don't appear to be trusting where PBMs are making their revenue, and rebate GPOs may be part of why.
On another page of the same survey, about 4 in 5 respondents had heard of the rebate group purchasing organizations (GPOs) that large PBMs now use to consolidate manufacturer negotiations, and most who had heard of them were at least moderately concerned about the shift.
Their concern is well-placed since GPOs are a major source of gross profits for PBMs.
↳ Here's a video breakdown for 2025 profit sources: https://t.co/Id5gIp6wSL
---
Perceptions of PBM transparency improved almost everywhere this year. Data access, formulary logic, audit rights, all moved in the right direction.
However, it doesn't seem like plan sponsors understand the market and legislative changes from the last year enough to say they will impact PBM revenue.
↳ That's completely fair since state PBM legislation has had limited success https://t.co/B0GYTUTcDB
What would you need to see as proof PBM legislation is working as intended?
🔗 Source: PSG 2026 PBM Customer Satisfaction Report https://t.co/GwHMb2TWgn
Site-neutral payments may reduce one incentive for hospitals to acquire physician practices.
But 340B creates another.
---
A new study in JAMA Health Forum led by Julia Thome suggests that the incentive to expand into off-campus care settings (i.e., vertical integration by acquiring local practices) persists even when Medicare pays site-neutral rates.
Note: The study used claims as an indicator of expansion. It could not distinguish acquisitions from newly developed sites or increased use of recently acquired sites.
The researchers examined Medicare FFS claims between hospitals that began participating in 340B with hospitals that did not.
After entering 340B, hospitals had an estimated:
🏥 83 more claims/quarter at newly established off-campus departments subject to site-neutral payment
💉 13 more drug administration claims/quarter at those sites
Maybe you can see why CMS finalized the rule for reduced Part B payments to 340B hospitals...
---
340B hospitals can purchase eligible outpatient drugs at discounted prices while generally receiving full reimbursement.
Expanding the number of patients treated at eligible off-campus sites can therefore create additional opportunities to administer 340B drugs.
That incentive is still there even when the payment for administering a drug is site-neutral.
---
Site-neutral payments alone don't eliminate the financial incentives for hospital acquisitions.
340B is still a strong force behind hospital consolidation.
Does anyone think the finalized ASP-28% payment for 340B hospitals address this (at least for Medicare)?
🔗 Source: JAMA Health Forum, Hospital 340B Participation, Site-Dependent Payment, and Vertical Integration https://t.co/dciXRuxEnA
From BlinkRx : BlinkRx Insights: Clarifying the Mystery around “DTP”
Learn more about BlinkRx's RxOS prescription operating system: https://t.co/WfGsVxugX8
Read the article: https://t.co/oPu4YvI8r4
#sponsored
More than 4 million Medicare beneficiaries will have their Medicare Advantage or stand-alone Part D plan terminated at the end of 2026.
---
A new @KFF analysis found that 4.3 million people are enrolled in plans that won’t be available to them in 2027:
🔹 3.1 million are in Medicare Advantage plans with drug coverage
🔹 1.2 million are in stand-alone prescription drug plans (PDPs)
For Medicare Advantage plans available for general enrollment, the number of people affected by terminations has more than doubled in two years:
📈 2025: Nearly 1.3 million
📈 2026: About 2.6 million
📈 2027: About 2.8 million
That represents 14% of enrollees in these plans for 2027.
Another 1.4 million Medicare Advantage enrollees are in plans being consolidated into another plan from the same insurer. They’ll be moved automatically and are separate from the 4.3 million full terminations.
---
PDP terminations are also affecting a larger share of enrollees.
6% of enrollees are getting hit by terminations for 2027, double the 3% affected for 2026.
↳ The major driver was 950k of the 1.2 million affected PDP enrollees in SilverScript Choice plans being terminated in 13 regions.
---
The average Medicare beneficiary can still choose from 28 MAPDs and 9 PDPs, but the terminations can be major issues for those in rural areas or those considering switching from Medicare Advantage to traditional Medicare (which isn't as simple as switching to another MAPD).
Would you say this decline falls under healthy competition?
Or a collapsing Part D market post-IRA?
🚨𝐃𝐢𝐬𝐢𝐧𝐭𝐞𝐠𝐫𝐚𝐭𝐢𝐨𝐧: 𝐀𝐝𝐚𝐦’𝐬 𝐅𝐨𝐮𝐫 𝐓𝐚𝐤𝐞𝐚𝐰𝐚𝐲𝐬 𝐟𝐫𝐨𝐦 𝐭𝐡𝐞 𝐂𝐕𝐒 𝐇𝐞𝐚𝐥𝐭𝐡 𝐁𝐫𝐞𝐚𝐤𝐮𝐩🚨
CVS Health is breaking up. Apparently, bigger wasn’t always better.
The split is a belated acknowledgement that the synergies between CVS Pharmacy and Caremark were overblown from the start.
An independent CVS Pharmacy will have greater freedom to make the hard choices—and find new friends.
Regulatory and legislative risks are real. But I view this primarily as a strategic and financial decision.
And vertical integration? Like a medieval peasant, it's not dead yet.
Read Adam's four takeaways 👉 https://t.co/FH6zaO773h
When affordability is the promise, who actually sees the savings?
Lower costs for one stakeholder can mean a higher bill for another. At the 2027 Drug Channels Leadership Forum, “Affordability Theatre: Who Really Pays?” will examine where savings are real, where costs are shifted, and how affordability claims hold up across the drug channel.
At the 2027 Drug Channels Leadership Forum, “Affordability Theatre: Who Really Pays?” will challenge the gap between political messaging, business models, and economic reality—and explore who ultimately pays across the drug channel.
Hear perspectives from:
▪️ Brooks Conway, FSA, MAAA, Principal | Oliver Wyman
▪️ Melissa Bartlett, Senior Vice President | The ERISA Industry Committee (ERIC)
▪️ Mike Kolodij, PharmD, Senior Vice President and Practice Lead, Health Plans | Pharmaceutical Strategies Group
Moderated by Bryce Platt, PharmD, RPh, Director | Drug Channels Institute
📅 March 15–17, 2027
📍 JW Marriott Miami Turnberry Resort & Spa
Request your invitation to take part in the conversation: https://t.co/RRpnQjZhoe
Invitation only. No press. No recordings.
#DCLF2027 #DrugChannels #DrugPricing #HealthcareAffordability
Without a 340B rebate model, drug manufacturers could face an estimated $6.1 billion in 340B and Medicare negotiated price overlaps in 2027.
---
New research from @IQVIA_global examines a growing source of duplicate discounts: drugs that receive both a 340B discount and a Medicare maximum fair price (MFP) refund.
A manufacturer generally cannot be required to provide a 340B price on an MFP drug unless the 340B price is lower than the MFP.
But identifying when both prices apply to the same drug isn’t straightforward.
↳ 340B operates on a purchase-based system, while Medicare’s MFP applies only to eligible prescriptions.
↳ Claims generally don’t identify whether a drug was purchased at the 340B price.
💸 IQVIA estimated potential 340B/MFP duplicate discounts of $6.1 billion in 2027 for drugs subject to MFP that year (using July 2026 prices).
These are modeled estimates of potential duplicate discounts, not an audit of actual duplicate payments. IQVIA used pharmacy claims, sales data, and a model that estimates the likelihood a prescription was 340B eligible.
---
HRSA’s revised 340B rebate model pilot is scheduled to begin January 1, 2027. Covered entities would submit data on eligible MFP drug claims so manufacturers can determine whether a 340B price is owed.
IQVIA estimates the pilot’s 2027 administrative, operational, and interest costs at $667 million, based on HRSA’s cost estimate and IQVIA’s interest assumptions.
Compare that to the $6.1 billion in duplicate discounts and you can see why it's a fair ask for a 340B program that can track details at the claims level, even if there is some cost/operational burden.
The main conflict in the debate here is the $6.1 billion is being saved by different entities than those paying the $667 million.
Tradeoffs across the system.
As I had predicted, the forces of deconsolidation are strong. Fortunately, I'm retiring and won't have to update my infamous vertical integration chart. 🙃
https://t.co/oDrabwOjPs
-Adam J. Fein
We’re delighted to welcome Archbow Consulting as a Silver Sponsor of #DCLF2027!
Don’t miss the opportunity to connect with Archbow Consulting and top industry leaders as we explore the challenges and opportunities shaping the future of drug channels.
✨ Learn more about available sponsorship opportunities: https://t.co/FyyEgBROHy
📅 March 15-17, 2027
📍 JW Marriott Miami Turnberry Resort and Spa
🎟️ Request an invite: https://t.co/8MtAons8wJ
#pharma #archbowconsulting #marketaccess #patientaccess #patientservices #biotech
𝐃𝐫𝐮𝐠 𝐂𝐡𝐚𝐧𝐧𝐞𝐥𝐬 𝐎𝐮𝐭𝐥𝐨𝐨𝐤 2027: 𝐀𝐝𝐚𝐦’𝐬 𝐅𝐢𝐧𝐚𝐥 𝐖𝐞𝐛𝐢𝐧𝐚𝐫
One last webinar. Plenty left to say.
📅 Friday, December 11, 2026
🕛 Noon–1:30 p.m. ET
📺 Replay and full slide deck included. Team discounts available.
𝐑𝐞𝐠𝐢𝐬𝐭𝐞𝐫 👉 https://t.co/x4JVm7NBZp
Adam J. Fein, Ph.D., is retiring from Drug Channels Institute at the end of 2026. Before he goes, join him on December 11 for Drug Channels Outlook 2027—his final DCI webinar.
After more than 20 years of tracking this industry, he’ll share his unfiltered, data-driven outlook on where it’s heading—and what that means for your business.
On the agenda:
↳ Consolidation, vertical integration, and industry power
↳ 340B and the 340Boom
↳ Accumulators, maximizers, and shady alternative funding programs
↳ The Gross-to-Net Bubble
↳ The Net Pricing Drug Channel
Antonio Ciaccia (@A_Ciaccia), Tyler Novotny, and Bryce Platt will join him to tackle PBM reform, new CMS and DOL rules, pharmacy profits, direct-to-patient disruption, and more.
And yes, expect SpongeBob SquarePants. 🧽
Bring your questions, too. During the live Q&A, you can unmute and engage directly with us.
I hope you’ll join Adam for his final DCI webinar.
𝐑𝐞𝐠𝐢𝐬𝐭𝐞𝐫 👉 https://t.co/x4JVm7NBZp
BREAKING NEWS: DCI has learned that @MedImpact Healthcare Systems, Inc. will acquire VytlOne PBM and Gateway Health Partners.
The proposed transaction excludes VytlOne’s 340B and pharmacy fulfillment assets.
---
The PBM shakeout is gaining momentum as pressures on PBMs intensify:
↳ Rising compliance costs from last week’s finalized DOL regulation, CAA 2026, and a patchwork of state regulations
↳ Smaller PBMs’ dependence on the Big Three for infrastructure, rebates, and pharmacy networks
↳ “Transparency” losing its power as a competitive differentiator
These pressures are making scale more valuable—and independence harder to sustain.
Adam Fein explored these dynamics and what comes next in his article and video from DCI’s April 2026 webinar:
👇🏻
PBM Shakeout: How Vertical Integration Is Reshaping What’s Next (VIDEO)
https://t.co/MPLAmkaHvO
---
With so many new requirements around transparency, what's really going to differentiate PBMs is how well they can deliver value like cost containment and reliable services to their customers, while still having the funds to be compliant with the laws.
Over the next ~five years, we expect many smaller PBMs to disappear through acquisition, consolidation, or business failure.
Add VytlOne to the consolidation bucket.
- Bryce Platt, PharmD
CMS projected that the average PDP premium would increase by less than $1/month in 2027.
KFF found it will actually be a 50% increase.
---
@KFF estimates that the average monthly premium for standalone prescription drug plans (PDPs) will rise from $34 in 2026 to $51 in 2027, assuming current enrollees remain in the same plan.
Some important stats from their analysis:
🔹 76% of PDP enrollees without low-income subsidies would pay a higher premium if they stay in their current plan.
🔹 2.4 million of those enrollees would see their monthly premium rise by more than $50.
🔹 The average PDP deductible will also rise, from $540 to $643 (the limit is $700 for 2027).
🔹 No PDPs will have a $0 premium in 2027. That affects 4.1 million people without low-income subsidies who are enrolled in $0 premium PDPs this year.
---
Why the gap between CMS and KFF?
CMS did not explain its calculation. One possibility is that CMS assumed people would switch to plans with lower premiums. This is why explaining your methods is important.
KFF expects the actual 2027 average will likely be lower than $51 once people switch plans and new beneficiaries enroll, but that means they have to shop for coverage.
Premiums are only one part of that decision. A lower premium almost guarantees different drug coverage, cost sharing, and/or pharmacy networks.
---
The average Part D drug premium in Medicare Advantage plans is projected by KFF to be much lower: $9 per month. MA plans can use rebates from the medical side of the business to reduce Part D premiums, an option unavailable to standalone PDPs.
However, the additional value being added to MAPDs (e.g., supplemental benefits) has been decreasing. It's just not showing up in the premiums.
For all Part D beneficiaries, reviewing next year’s premium AND coverage could be especially important.
From Courier Health: Biopharma’s AI Fork in the Road
Download Courier Health's whitepaper about patient experience innovation in 2027: https://t.co/hYV9Chx6XH
Read the article: https://t.co/ErDDcKVdla
#sponsored
Match the patients. Standardize drug reimbursement.
Medicare outpatient drug spending is still higher at 340B hospitals.
---
A new Milliman analysis commissioned by PhRMA compared Medicare Part B drug spending between 340B and non-340B hospitals (no grantees).
The authors matched patients on measured characteristics and standardized reimbursement to ASP+6% for affected claims in order to remove the most relevant confounding variables between 340B and non-340B patients.
From 2019 through 2024, spending per drug utilizer was 20% to 52% higher at 340B hospitals (check the paper methodology for why the 52% in 2024 may need to be adjusted to the alternative figures in the paper).
---
What contributes to the remaining difference?
💊 More utilization
↳ Patients at 340B hospitals had 15%-32% more outpatient drug claims per utilizer in 2019-2024.
💰 Higher spending per claim
↳ Allowed spending per claim was 6%-41% higher.
↳ That can mean more expensive drugs were given, more units administered per claim, or both.
To be clear, this study identifies the two contributors to higher spending above (since reimbursement was all repriced to ASP+6%), but it doesn't establish that 340B participation caused the differences.
---
If you're interested in other breakouts, the appendices have more slices of the data looking at DSH, bed count, age of patient, years since starting the hospitals' 340B program, urban/rural, dual eligibility, and many more.
What's your takeaway from this more rigorous comparison of 340B hospitals?
🔗 Source: Milliman https://t.co/1pCIUu8u78
When you get an infusion or injection from a provider, the price was likely determined by ASP.
Here's what ASP actually means.
---
Average Sales Price (ASP) is a volume-weighted average of what manufacturers charge U.S. purchasers, net of rebates, chargebacks, and other price concessions.
Since 2005, it has replaced Average Wholesale Price (AWP) as the basis for Medicare Part B reimbursement of provider-administered drugs.
Many other payers also use ASP in their reimbursement contracts.
---
A few things make it trickier than "average price":
📅 It's published on a two-quarter (6-month) lag. The price Medicare pays today reflects manufacturer sales from two quarters ago
🚫 Medicaid rebates and 340B discounts are excluded from the calculation, so ASP runs higher than a manufacturer's true blended net price across all channels
🏷️ It's calculated per HCPCS billing code (J-codes for most drugs), not per manufacturer or package size. Multi-source generics with several manufacturers all get blended into one ASP.
ASP also bends around a few specific situations:
↳ New drugs without pricing history get reimbursed off WAC (103%) until a real ASP can be calculated
↳ New biosimilars get an even bigger boost because their add-on is calculated as a share of the reference product's ASP until they get their own, and the IRA temporarily bumped that from 6% to 8% ending 2028
↳ CMS has proposed paying certain 340B-acquired drugs at ASP-33.4% starting 2027, which CMS estimates would cut Medicare payments by $4.55 billion and beneficiary cost sharing by $1.15 billion in a single year.
---
ASP is kind of like NADAC for medical benefit drugs, but better for many of the reasons I cover in this post: https://t.co/9IVg0l3GQ9
That doesn't mean there isn't room for improvement.
What changes would you make to ASP?
🔗 Source: DCI's 2026-27 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors https://t.co/josWTa8vfv
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