2026 Medicare Update: 10 High-Cost Drugs Expected to See Pricing Changes
The 2026 Medicare update includes an assessment of ten high-cost medications that exert substantial financial pressure on the healthcare system, along with an examination of how the program’s broader Prescription Drug Price structure may evolve. This educational overview explains why certain medications are included, which criteria guide the evaluation, and how Medicare approaches potential pricing adjustments. No medical advice or individualized pricing forecasts are provided.
Medicare is preparing a major shift in how it pays for certain prescription drugs. Beginning in 2026, a set of high-expenditure, single‑source medicines in Medicare Part D will have negotiated prices that aim to balance patient access, clinical value, and sustainable spending. The change follows a structured process defined by federal law and will roll out alongside broader improvements to prescription drug benefits. This article is for informational purposes only and should not be considered medical advice. Please consult a qualified healthcare professional for personalized guidance and treatment.
Why Medicare Is Updating Prices for High-Cost Drugs in 2026
Prescription drug spending in Medicare Part D has grown faster than many other parts of the program, driven by brand-name drugs without generic or biosimilar competition. The 2026 update introduces negotiated prices—known as a Maximum Fair Price (MFP)—for a limited group of drugs with the highest overall spending in Part D. The goals are to reduce beneficiary out-of-pocket costs, moderate plan and federal spending, and encourage value-driven use of medicines while maintaining access to clinically important therapies.
How the 10 High-Cost Medications Were Selected for Review
The law directs Medicare to identify single‑source brand drugs (or biologics) with the highest Part D spending that also meet eligibility rules. In general, a drug must have been on the market long enough to allow negotiation—typically 9 years from initial FDA approval for small‑molecule drugs and 13 years for biologics—and must lack approved generics or biosimilars marketed in the U.S. Medicare then ranks eligible products by total gross Part D spending and selects a defined number for negotiation, which totals ten for the first year of implementation in 2026.
How Medicare Evaluates Possible Pricing Changes
For each selected drug, Medicare reviews multiple statutory factors. These include evidence of clinical benefit and comparative effectiveness versus therapeutic alternatives; the severity of the condition and unmet medical need; real‑world utilization across patient groups; and economic considerations such as research and development costs, production and distribution expenses, prior federal support, and market dynamics. After exchanging offers and counteroffers with manufacturers, Medicare sets a Maximum Fair Price. These negotiated prices are scheduled to take effect for Part D plans beginning in 2026, with further expansions of the program in later years.
What Expected Price Adjustments Mean for Medicare Users
For people enrolled in Medicare prescription drug plans, negotiated prices can influence both premiums and point‑of‑sale costs. In 2025, the Part D benefit will also cap annual out‑of‑pocket spending at $2,000 and add an option to spread payments over the year, potentially making high‑cost medicines more manageable. In 2026, the negotiated MFPs for the selected drugs may further reduce coinsurance and copays because beneficiary cost‑sharing is often calculated as a percentage of the plan’s allowed price. Plan formularies and prior authorization policies may also evolve as negotiations take effect.
Practical pricing insight for 2026: While Medicare will publish the negotiated MFPs before they take effect, real‑world spending depends on plan design, phase of the benefit, and whether a drug is filled at a preferred pharmacy. Below are example products commonly cited in public reporting on the 2026 negotiation cohort, with approximate cash/list price ranges for a 30‑day supply as context. These are not the negotiated prices and actual patient costs under Medicare may be lower due to plan benefits.
| Product/Service | Provider | Cost Estimation |
|---|---|---|
| Eliquis (apixaban) 5 mg | Bristol Myers Squibb/Pfizer | $500–$650 per 30 days |
| Xarelto (rivaroxaban) 20 mg | Janssen (J&J)/Bayer | $450–$620 per 30 days |
| Jardiance (empagliflozin) 10 mg | Boehringer Ingelheim/Eli Lilly | $500–$620 per 30 days |
| Farxiga (dapagliflozin) 10 mg | AstraZeneca | $500–$620 per 30 days |
| Januvia (sitagliptin) 100 mg | Merck | $450–$600 per 30 days |
| Entresto (sacubitril/valsartan) | Novartis | $500–$700 per 30 days |
| Imbruvica (ibrutinib) | AbbVie/Janssen | $12,000–$14,000 per 30 days |
Prices, rates, or cost estimates mentioned in this article are based on the latest available information but may change over time. Independent research is advised before making financial decisions.
The figures above reflect typical list‑price ranges observed in the commercial market and do not represent what Medicare beneficiaries actually pay. Under Part D, out‑of‑pocket amounts depend on negotiated plan prices, benefit phase, low‑income subsidies, and in 2025 onward, the annual $2,000 cap and smoothing option. Negotiated MFPs in 2026 are expected to influence these underlying plan prices for selected drugs, which in turn can lower coinsurance amounts for many enrollees.
In addition to direct point‑of‑sale effects, price updates may have indirect impacts. Plans could adjust premiums based on anticipated spending, though these changes vary by region and contract. Some beneficiaries may see changes to preferred pharmacies or utilization management as plans align formularies with the negotiated prices. People with complex regimens should review their plan materials carefully during open enrollment and discuss therapeutic alternatives with their clinicians when appropriate.
In summary, the 2026 Medicare update introduces negotiated prices for a limited set of high‑spend Part D medicines to improve affordability and value. Selection is grounded in clear eligibility criteria and spending data, and evaluations weigh clinical benefit alongside economic factors. Combined with the 2025 out‑of‑pocket cap, these changes are designed to make prescription costs more predictable for Medicare users, while preserving access to clinically important treatments.
