The Inflation Reduction Act’s first set of negotiated Medicare drug prices took effect on January 1, 2026, covering ten medications: Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and Fiasp/NovoLog. The negotiated prices apply to Medicare Part D, which means most patients receiving these drugs see lower out-of-pocket costs and Part D plan formularies tilt toward the negotiated drugs. For practices that prescribe these medications heavily (cardiology, endocrinology, rheumatology, oncology, hematology), the IRA changes ripple into prior authorization patterns, formulary adherence, patient assistance programs, and downstream care management billing. The medications are still covered. The economics around them have changed.
What changed at the prescription point
The negotiated Maximum Fair Price (MFP) sets the price Part D plans pay manufacturers for the listed drugs. Medicare Part D plans must cover the negotiated drugs on their formularies. Patient cost-sharing under the new $2,000 annual out-of-pocket cap, also IRA-driven, makes these drugs substantially more affordable than in 2024. From the practice’s perspective, prescribing has not changed. The drugs are still on prior authorization for many indications, the dosage and indication rules are the same, and the prescription workflow is unchanged. What has changed is patient access. More patients can afford the negotiated drugs, and prescribing volume in some categories will rise.
Implications for cardiology practices
Cardiology has four drugs on the first list: Eliquis, Xarelto, Entresto, and Jardiance. Anticoagulation prescriptions (Eliquis and Xarelto) were already high-volume; with negotiated prices, patient adherence improves as out-of-pocket costs fall, which tends to raise the overall prescription rate. Entresto for heart failure and Jardiance for both heart failure and diabetes are increasingly first-line, and lower out-of-pocket costs accelerate uptake. Practices should expect higher prescription volume, and downstream care management billing (CCM, APCM, transitional care management) is likely to scale with it. The administrative challenge is the volume increase; the clinical opportunity is improved adherence on patients who previously cycled off the drugs for cost reasons.
Implications for endocrinology and primary care
Januvia, Farxiga, and Jardiance for diabetes are on the negotiated list, alongside the Fiasp/NovoLog insulin pair. The clinical guidelines around SGLT2 inhibitors and DPP-4 inhibitors continue to expand, with Farxiga and Jardiance now indicated for kidney disease and heart failure beyond their original diabetes indications. Lower out-of-pocket costs combined with broader indications mean these drugs reach more patients with renal and cardiac comorbidity. For primary care and endocrinology practices, the billing implications are similar to cardiology: more prescriptions, more chronic care management billable through APCM and CCM, and a potential reduction in expensive complications such as hospitalizations, which feed favorably into MIPS and value-based contracts.
Specialty practices: rheumatology and oncology
Enbrel for rheumatoid arthritis and other autoimmune conditions, Stelara for psoriasis and Crohn’s, and Imbruvica for chronic lymphocytic leukemia and other hematologic cancers, are on the list. These specialty drugs typically require complex prior authorization and patient assistance program navigation. The IRA changes have not eliminated prior authorization, and several payers have raised utilization management requirements in parallel with the price changes. Specialty practices should expect prior authorization workload to remain steady or rise, even as patient out-of-pocket costs fall. The infusion-related billing (administration, drug, and chair time) is unchanged.
Patient assistance program changes
Manufacturer-sponsored patient assistance programs that previously offset high out-of-pocket costs for the listed drugs have updated their eligibility criteria and benefit levels in 2026, with some narrowing assistance to a smaller patient population given the lower price floor. Practices that have leaned on PAP enrollment to keep patients on therapy should review the 2026 program rules for each drug and update their financial counseling workflow accordingly. Patients newly able to afford the medication directly may not need PAP at all; patients still struggling with cost may have fewer external supports than before.
The next round of negotiated drugs
CMS announced the next 15 drugs subject to negotiation, with prices effective January 1, 2027. The expanded list includes drugs across diabetes, oncology, and immunology categories. Practices with patients on these drugs should expect similar dynamics in late 2026: prior authorization patterns may shift, formulary status may change, and patient assistance programs may update. The discipline that handles 2026 cleanly carries forward to the 2027 expansion.
How MHB helps practices through the transition
For practices managing higher prescription volume on the negotiated drugs and the downstream care management billing that follows, our team supports end-to-end medical billing including infusion administration coding, APCM and CCM management, and prior authorization workflow tied to the practice’s specialty mix.
The bottom line
The IRA’s first negotiated drug prices changed patient access, not the prescription workflow. Practices serving cardiology, endocrinology, rheumatology, oncology, and primary care patients should expect higher volumes on the listed drugs, more adherence at the chronic-condition level, and downstream care management revenue scaling with it. Practices that build prescribing and care management capacity for the change capture the upside. Practices that stay on autopilot watch the volume happen without billing for it.
Authoritative sources
This article cites the following primary sources for billing-code and regulatory guidance. Always confirm current rules and codes with the publishing authority before applying to a specific claim.
