Does the 2026 Medicare Formulary Review for MFP Drugs Reflect Fairness or Missed Potential?

Introduction: The Inflation Reduction Act (“IRA”) and the Origins of Maximum Fair Price (“MFP”)

The introduction of MFP represents a philosophical turning point in U.S. drug pricing—shifting negotiation from private discussions between pharmaceutical manufacturers and payers with oversight from the Centers for Medicare and Medicaid Services ("CMS") to a public instrument between manufacturers and CMS and the Trump Administration. Yet the underlying question remains: did/can/should/could transparency alone alter behavior within a rebate-driven system?

The IRA was positioned as a transformative policy—one designed to balance affordability for patients and savings for the government with sustainability for innovation. At its core, the law introduced the concept of the MFP, establishing a government-negotiated ceiling price for select Medicare drugs beginning in 2026. These prices were expected to catalyze new access dynamics, rebalance power in manufacturer–payer negotiations, and redefine how "value" is operationalized in drug coverage decisions.

Yet as the first negotiated drugs move toward implementation, early formulary data suggest a different reality—one of parity rather than preference within the medicare formulary landscape. The MFP program may have lowered nominal prices, but it has not yet shifted the architecture of access.

The First 10 Negotiated Drugs and Their Role in Medicare Part D Formulary Dynamics

As shown in the table below, MFPs for the first 10 high-expenditure Part D drugs range from a 79% discount to a 38% discount off the 2023 List Price. This cohort also functions as a stress test: if MFP cannot move placement in these well-rebated, high-spend classes, it is unlikely to do so in lower-spend categories without complementary contractual innovation.

Table 1: First 10 Negotiated Drugs MFP

Note: Numbers other than prices are rounded to the nearest thousands. List prices are rounded to the nearest dollar and represent the Wholesale Acquisition Costs (WACs) for the selected drugs based on 30-day supply using CY 2022 prescription fills. Drug companies' participation in the Negotiation Program is voluntary; the figures above represent estimates based on continued drug company participation in the Medicare program.

The initial cohort of negotiated drugs spans cardiovascular, diabetes, oncology, autoimmune, and hematology categories. They include Eliquis, Xarelto, Jardiance, Januvia, Farxiga, Imbruvica, Stelara, Enbrel, Fiasp, and Entresto. These therapies were chosen based on Medicare spend, duration on market, and lack of generic or biosimilar competition. In practice, these selections represent both the highest fiscal burden and the most entrenched rebate ecosystems in Part D.

This diverse list serves as a useful lens for understanding early formulary reactions and how the medicare part D formulary is adapting to the IRA’s policy changes.

What the 2026 Medicare Formulary Data Reveals About MFP Drugs

An analysis of 2026 PDP formularies across leading plans—including Silverscript (Aetna), Wellcare, AARP, Humana, and Kaiser Permanente—shows that MFP drugs are not receiving preferential placement compared to competitors. In fact, the data indicate consistent parity in both tiering and utilization management (UM) restrictions.

Detailed findings for the formulary of each Negotiated Drug (“ND”) and their competitors in key Medicare plans are as follows:

Diabetes

Psoriasis/Psoriatic Arthritis

Blood Clots

Blood Cancer

Interpreting Parity in the Part D Formulary: Why Drug Pricing Shifts Have Not Moved Placement

The parity observed is neither accidental nor purely political—it is the predictable outcome of entrenched payer infrastructure and the sequential nature of formulary decision-making. The IRA’s MFP mechanism was conceived to introduce pricing transparency and equitable access; however, its translation into real-world coverage reflects how Part D plans, PBMs, and GPOs integrate new pricing benchmarks within established contracting, compliance, and value-assessment frameworks. Three reinforcing dynamics appear to explain the lack of differential placement observed across the 2026 formularies:

Taken together, these forces suggest that MFP’s early impact is more optical than operational. The inertia of contracting cycles, the rigidity of compliance frameworks, and timing misalignment collectively temper its immediate influence on access. The program’s long-term effectiveness may depend less on the authority to negotiate and more on how well outcomes are communicated, timed, and embedded within payer decision processes.

What These Trends Mean for Manufacturers and Payers in a New Drug Pricing Era

For payers, the next negotiation cycles will likely focus less on list-price delta and more on how manufacturers align those rebates with therapeutic differentiation—particularly through outcomes-based arrangements or evidence-linked rebates.

Manufacturers should assume flat access with tighter net price corridors and shift negotiation energy toward outcomes-based constructs, indication-specific rebates, and evidence-linked guarantees that create contractual reasons to move placement—beyond the MFP signal alone.

For manufacturers, the data underscore a hard truth: MFP participation does not automatically translate into preferred access. The downward pressure on list price compresses revenue but has not yet increased volume. Payers, meanwhile, appear content maintaining equilibrium—leveraging MFP outcomes as negotiation benchmarks without rewriting access logic.

This suggests a future where value communication, clinical differentiation, and contracting strategy will matter more than statutory pricing. The early MFP experience is therefore not a story of disruption, but of reversion to mean—market efficiency overriding policy intent.

Looking Ahead: Early 2026 Claims as the Real Test

The first six months of 2026 will be telling. If patient cost-sharing reductions under MFP pricing drive measurable uptake, payers may recalibrate formulary positions in the next cycle. Conversely, if utilization remains stable, the MFP program may stand as a symbolic victory without a structural one.

CultPAVE powered by MME will continue tracking PDP-level claim activity in these therapeutic areas and will issue an update in mid-2026. The key metric will be not list price, but realized patient access and adherence.