CMS Announces 15 Additional Drugs for Medicare Price Negotiation

In This Edition:

• 15 Drugs Selected for Second Round of Negotiations Under the Medicare Drug Price Negotiations Program
• Critical Network Update: Rothman Orthopaedics Out-of-Network for Highmark MA Members Effective April 1, 2025 (SEPA)
• Contacts and Additional Resources

15 Drugs Selected for Second Round of Negotiations Under the Medicare Drug Price Negotiation Program

CMS recently announced the 15 Part D drugs selected for the second round of negotiations under the Medicare Drug Price Negotiation Program.

Negotiations with participating manufacturers of the 15 selected drugs, mandated by the Inflation Reduction Act, will take place in 2025, with resulting lower prices taking effect in 2027.

The drugs selected for the second round of negotiations are:

For a fact sheet about the second round of price negotiations, click here.

Additionally, On January 29, CMS issued a statement confirming the agency’s commitment to incorporating lessons learned from the first round of negotiations of the Medicare Drug Price Negotiation Program in future rounds, including greater transparency into the program.

Critical Network Update: Rothman Orthopaedics Out-of-Network for Highmark MA Members Effective April 1, 2025 (SEPA)

Effective April 1, 2025, Highmark Medicare Advantage members will no longer have in-network access to Rothman Orthopaedics professional and Durable Medical Equipment services.

As part of our market entry strategy in southeastern Pennsylvania (SEPA,) Highmark began offering new Medicare Advantage (MA) plans in the region effective Jan. 1, 2025. This means that Highmark has contracted with local providers for new agreements that allow MA members to continue to access care. However, amongst these local providers, Rothman Orthopaedics has chosen to terminate their MA agreement. This termination is effective April 1, 2025.

We do not anticipate any gaps in care for members as services provided by Rothman Orthopaedics can be provided by other area professional and Durable Medical Equipment (DME) providers. Highmark will continue to have a robust network of professional providers and DME suppliers in the SEPA region without Rothman Orthopaedics. MA members are encouraged to call the number on the back of their ID card or use Highmark’s online provider directory to find alternative, in-network professional and ancillary providers. Members can always find alternative in-network doctors and hospitals by logging in to the member portal online or through the MyHighmark app.

Certain plans, specifically Group MA, have out-of-network benefits that may allow members to continue seeing Rothman Orthopaedics.  Members can learn more about their benefits by leveraging self-service tools or by contacting customer service. While members may have out-of-network coverage with their Highmark Medicare Advantage plan, Rothman Orthopaedics providers and facilities may choose to deny care for Highmark Medicare Advantage members. Each provider and facility within Rothman Orthopaedics may have different policies regarding whether they will accept a Highmark Medicare Advantage member. We recommend members call the office of the Rothman Orthopaedics provider(s) they are interested in seeing to discuss their coverage prior to their visit. 

We will be sending letters beginning March 2, 2025 to all members who have utilized services with Rothman Orthopaedics in the past 12 months. These letters will provide information on how to apply for continuity of care and how to find other in-network providers. Highmark reserves the right to adjust this communication plan as needed.

Highmark continues to have an agreement with Rothman Orthopaedics for Commercial, FEP, ACA and Highmark CHIP members, and Rothman Orthopaedics will remain in network for those members.

The information on this website is for agent use only and not intended for the general public.