Medicare Part B Drug-Pricing Reforms Coming in 2026—What Providers Should Do Now

CMS’s Contract-Year 2026 Final Rule (CMS-4208-F) and related guidance turn Inflation Reduction Act concepts into operational reality for Part B drugs. Add the forthcoming WISeR prior-auth pilot and you have the most radical overhaul of Medicare pharmacy policy since 2003.

Snapshot of 2026 Changes

Price Negotiation: The first 15 high-spend Part B biologics enter negotiation; ceiling prices publish Sept 1 2026.
Prescription Payment Plan: Part D out-of-pocket cap set at $2,100 and spread over 12 installments.
Prior-Authorization Expansion: Traditional Medicare adds AI-enabled PA for 17 services in NJ, OH, OK, TX, AZ, WA under WISeR.
Site-Neutral Study: EO-driven analysis may tie Part B payment to physician-office rates by 2028.

Financial Impact on Infusion Centers

Health-economics models estimate negotiated prices could trim Part B reimbursement 15 – 25 % for selected drugs, with commercial payers likely to follow within two years. Margin compression will be most acute for buy-and-bill oncology practices.

Four “No-Regrets” Moves for 2025

1. Map Exposure to Negotiated Molecules

Cross-walk your top-20 Part B drugs against CMS’s negotiation-eligibility list; flag anything >10 % of drug revenue.

2. Rebalance Charge Capture

Align HCPCS unit definitions and wastage billing; CMS auditors identified $160 million in wastage-related overpayments in 2024.

3. Strengthen PA Automation

WISeR will require machine-readable documentation. Early adopters using AI-assisted PA have reduced denial-overturn time by ~40 %.

4. Scenario-Plan Site-Neutral Cuts

A 12-chair HOPD moving 30 % of infusions off-campus avoided a projected 9 % revenue loss under simulated site-neutral rates.

Conclusion

Medicare’s 2026 reforms will squeeze drug margins while tightening administrative rules. Providers that pre-model price cuts, embrace biosimilars, and automate prior auth will turn disruption into a competitive edge—and ensure patients keep receiving the treatments they need