Future IRA Drug Negotiations Expected to Compound Pharmacy Burden

Pharmacies navigating the financial strain of Inflation Reduction Act (IRA) drug pricing in 2026 should brace for more of the same in the years ahead as the number of negotiated drugs grows annually and the price tags of newly selected medications push the cash flow gap even higher.

“In terms of what we've actually seen on the ground from pharmacies, we have seen some survey data released that most pharmacies are waiting upwards of at least 22 days, which is the timeline that we outlined in guidance and regulations [and] expected,” Allison Schneider, MPH, director at ADVI Health, told Drug Topics®. “But at least a quarter are waiting more than that, potentially over a month, which could be impacting their ability to provide services to patients.”

In this week’s episode of the Over the Counterpodcast, Schneider joined to provide notable updates and developments regarding the first year of Medicare drug price negotiations. From the continued cash flow disruptions to operational challenges ahead in 2027, she provides necessary insight into how community pharmacies can prepare for more negotiation.

READ MORE: FAQ: Policies for Pharmacists to Track Heading into 2026 Midterms

Growing Capital Deficits and Retrospective Payment Delays

At the center of this financial squeeze is the retrospective rebate mechanism governing maximum fair price reimbursement. Rather than purchasing medications at negotiated rates at the point of sale, pharmacies must purchase inventory through standard wholesale channels at full wholesale acquisition cost (WAC).¹

When dispensing to a Medicare Part D beneficiary, the pharmacy initially receives only the maximum fair price plus a dispensing fee. The remaining balance, termed the standard default refund amount, must be recovered through retrospective manufacturer rebates via the Medicare Transaction Facilitator (MTF).^1,2

An RxTrail operational guide warns that this process creates acute liquidity gaps, extending reimbursement from 14 days to 22 or 24 days. For 340B covered entities, coordinating claims between the Beacon clearinghouse and the facilitator adds further administrative friction as wholesaler invoices fall due.

This cash flow burden will compound as negotiation lists expand. In 2026, the program applied to 10 Part D drugs, but the Centers for Medicare and Medicaid Services (CMS) has 15 additional therapies taking effect in 2027. Schneider stressed that the 2027 group includes higher-cost specialty and oncology products like Austedo, Calquence, and Xtandi, requiring pharmacies that dispense those drugs to float thousands more dollars per script while awaiting refunds.³

Looking ahead, CMS confirmed in March 2026 that manufacturers of all 15 drugs selected for 2028 agreed to participate, introducing Part B physician-administered therapies and establishing annual additions of 20 drugs. Meanwhile, CMS removing drugs from the negotiated list, like Stelara and Xarelto due to generic competition, force pharmacies to navigate constantly shifting reimbursement rules.

Vanishing Margins and Threats to Pharmacy Solvency

Beyond payment lags, negotiated pricing degrades underlying dispensing margins. A study in the Journal of Managed Care and Specialty Pharmacy estimates that maximum fair price reimbursement could trigger an 85% revenue reduction for negotiated drugs in long-term care (LTC) pharmacies, exceeding $3 billion in 2027.²

Historically, branded drug reimbursement based on average wholesale price helped offset inadequate dispensing fees. Under the new policy, margins for a 30-day supply of rivaroxaban drop from $42 to an $8 dispensing fee, while therapies like deutetrabenazine plunge from an $849 margin down to $8 as well. Without legislative relief, 60% of LTC pharmacies expect to close locations and 90% anticipate layoffs.

These pressures are intensified by wider payer behavior. An analysis in HealthVerity noted that the Part D benefit redesign shifts catastrophic liabilities to plans, while negotiated drugs become the de facto baseline price for therapeutic classes.^4,5

Although plans must cover negotiated drugs, the statute does not guarantee preferred tier placement, exposing pharmacies to volatile cost-sharing collection risks. Simultaneously, experts have reported that pharmacy benefit managers (PBMs) are deploying aggressive contracting tactics to control access.

To prepare for the years ahead, pharmacists must automate rebate tracking, evaluate specialty exposure, and advocate for sustainable dispensing fees before expanding negotiations further jeopardize community access.^1,2,5

READ MORE: Law and Regulations Resource Center

REFERENCES

1. The IRA’s impact on retail pharmacy operations: a readiness guide for covered entities. RxTrail. February 12, 2026. Accessed October 23, 2026. https://www.rxtrail.com/post/the-iras-impact-on-retail-pharmacy-operations-a-readiness-guide-for-covered-entities

2. Bhardwaj S, Schmutz HW, Watanabe JH, et al. Challenges of the Inflation Reduction Act for long-term care pharmacy: examining impact and policy solutions. JMCP. 2026;32(4):498-506. doi:10.18553/jmcp.2026.25312

3. Selected drugs and negotiated prices. Centers for Medicare & Medicaid Services. September 22, 2026. Accessed October 23, 2026. https://www.cms.gov/initiatives/medicare-prescription-drug-affordability/overview/medicare-drug-price-negotiation-program/selected-drugs-negotiated-prices

4. Doyle J. Drug price negotiation in 2026: how the Inflation Reduction Act is changing pharma strategy. Yes& Agency. April 10, 2026. Accessed October 23, 2026. https://yesandagency.com/drug-price-negotiation-2026-ira-pharma/

5. Hale C. Navigating the impacts of the Inflation Reduction Act (IRA): strategic considerations for pharma. HealthVerity. July 10, 2026. https://blog.healthverity.com/navigating-the-impacts-of-the-inflation-reduction-act-ira-strategic-considerations-for-pharma