Pharmacy & Drug Pricing

Synthesis:

Over the last 30 days, CMS finalized significant 2027 Medicare Advantage (MA) and Part D payment policies that reshape risk adjustment, capitation rates, and plan accountability—culminating in a 2.48% average MA rate increase and finalized Part D risk adjustment changes that differentiate MA-PDs from standalone PDPs. These policy shifts, alongside CMMI’s ongoing rollout of the BALANCE program to expand equitable access to GLP-1 therapies for obesity and related conditions, signal a structural commitment to aligning drug coverage, payment models, and quality incentives across MA and Medicaid. For value-based care leaders, these developments will drive meaningful changes in plan bidding, formulary design, and care management approaches across ACOs and population health programs, especially as CMS codifies a long-term strategy to control specialty drug spend while extending targeted VBC innovation. Key details available from CMS 2027 MA and Part D payment policy finalization and the BALANCE model for GLP-1s in Medicare and Medicaid.