In August 2026, NICA submitted comments to the Senate Finance Committee on proposals to lower prescription drug costs. NICA highlighted several policies that can affect what patients pay for their medications and providers’ ability to deliver care, including government drug price setting, copay accumulator and maximizer programs, and the role of pharmacy benefit managers (PBMs).
August 11, 2026
The Honorable Ron Wyden
Senate Finance Committee
219 Dirksen Senate Office Building
Washington DC 20510
Re: Request for Information: Commonsense Policy Options to Lower Drug Prices for Patients
Dear Senator Wyden and members of the Senate Finance Committee:
The National Infusion Center Association (NICA) is a nonprofit organization formed to support non-hospital, community-based infusion centers caring for patients in need of provider-administered medications. To improve access to medical benefit drugs that treat complex, rare, and chronic diseases, we work to ensure that patients can access these drugs in safe, more efficient, and cost-effective alternatives to hospital care settings. NICA supports policies that improve drug affordability for beneficiaries, increase price transparency, reduce disparities in safety across care settings, and foster patient access to the highest-quality, lowest-cost setting.
NICA’s members administer medications to patients – including Medicare beneficiaries – with serious conditions such as autoimmune disease, which is lifelong and can result in permanent disability if not managed appropriately upon diagnosis. Fortunately, the treatment of autoimmune disease, including such conditions as rheumatoid arthritis, psoriasis, and lupus, has come a long way in that there are now specialty biologics that enable patients to manage their condition, in many cases with such success that these patients are able to fully engage in activities of daily living or remain employed in the same way they were prior to diagnosis.
We appreciate the opportunity to provide comments on Request for Information: Commonsense Policy Options to Lower Drug Prices for Patients, Sections I and II and how these proposals will impact infusion providers nationwide as well as the patients they serve.
SECTION 1: LOWERING DRUG PRICES
Factoring international prices into Medicare drug price negotiation
As Part B providers, NICA has been actively engaged with Congress and the Centers for Medicare & Medicaid Services (CMS) throughout the passage of the Inflation Reduction Act and the Medicare Drug Price Negotiation Program. NICA has further engaged CMS when the Most Favored Nation (MFN) Model was proposed in 2020 and later rescinded in 2021, as well as recent proposals by Congress. We remain concerned by the way in which international price setting policies will potentially limit patient access and strongly discourage Congress from advancing policies that set the price of drugs based on those prices set by foreign nations.
In 2020, CMS confirmed that a portion of the Model’s savings would be “attributable to beneficiaries not accessing their drugs through the Medicare benefit, along with the associated lost utilization.” In other words, as a result of the Model, beneficiaries would lose access to their medicines. The essential medications offered at infusion centers are often the only (or most effective) medications for the devastating conditions treated by our providers. Disrupting or delaying access to those drugs will have dire and permanent consequences for patients. We strongly believe that loss of access is the main reason the international price setting must be rejected by Congress.
Furthermore, infusion practices rely on an add-on payment which is based on a percentage of the Average Sales Price (ASP) of infused medications. This add-on payment allows our members to account for acquisition costs, but these margins are incredibly slim. MFN proposals that do not also adjust the add-on payment for infused medications will make it untenable for our members to provide these critical services within their communities. At a time when medical practices are already struggling due to recurring Medicare reimbursement cuts, inflation and sequestration, an insufficient add-on payment due to MFN could put some infusion centers underwater. Our members serve a valuable role in the community, providing localized care at a safe and cost-effective site, and it’s critical that Congress does not advance policies that threaten the viability of these sites of care. We urge Congress to not advance MFN proposals because we are deeply concerned that it may severely limit patients’ ability to access needed medications.
Developing Incentives to Support Biosimilars
CMS is currently providing inadequate reimbursement for certain Part B biosimilar medications. Much like brand biologics, biosimilars are complex medications that often require administration via injection or infusion at a center. These medications are administered routinely to patients with chronic conditions, including arthritis, osteoporosis, asthma and other immunodeficient illnesses. Through biologic and biosimilar infusions, patients can live healthier and more productive lives, avoiding long-term disability and costly trips to the hospital for disease related complications.
Much like generic drugs, biosimilars offer a more cost-effective alternative to brand name biologic drugs, and NICA supports the goal of developing incentives that support biosimilar adoption. However, pharmacy benefit managers (PBMs) have corrupted the marketplace by requiring sizable rebates or other price concessions to secure formulary placement for biosimilars. This causes a ripple effect throughout the system that results in a reduced average sales price (ASP) and ultimately, significant reimbursement cuts.
While reductions and cuts may sound positive, PBMs have managed to make the most cost-effective drug unaffordable for providers and thus inaccessible for patients. While the PBMs benefit from large rebates or fees, infusion centers are squeezed because these concessions are reflected in the calculation of ASP, which can drive down reimbursement while providers’ acquisition costs do not decline, leaving infusion practices financially underwater As a result, infusion centers must administer these biosimilars at a financial loss, which is unsustainable. In a recent survey conducted by the National Infusion Center Association, 74% of surveyed infusion providers indicated that they have been affected by biosimilar reimbursement rates that are lower than acquisition cost.
Unfortunately, this underwater reimbursement for biosimilars has put infusion centers in a difficult situation in which they must choose to continue operating in the red on these biosimilar infusions or transfer patients to a hospital, where these immunocompromised patients are susceptible to infection. As Congress considers opportunities to develop incentives to support biosimilars, NICA strongly encourages Congress to also address the systemic problems in the system that drive underwater reimbursement, thus limiting access to these lifesaving biosimilar medications.
SECTION II: ENHANCING PRESCRIPTION DRUG AFFORDABILITY
Recommendations on how to make Part B drugs more Affordable to Beneficiaries
Infusion patients often suffer from chronic and autoimmune conditions that require treatment with specialty biologics. For many Medicare beneficiaries, Part B drugs are essential for managing these conditions and maintaining their health and independence. However, patient out-of-pocket costs consistently challenge continuity of care as patients struggle to afford their medications. These medications are complex and often expensive. Under Original Medicare, beneficiaries generally remain responsible for 20% of their covered Part B drugs even after hitting their deductible leading to high out-of-pocket costs for those without supplemental coverage. This is especially hard for Medicare Advantage patients who may have high-deductible health plans and often have different deductibles, copayments, or coinsurance in general from Original Medicare depending on their plan. When a patient’s cost-sharing is too high, they may ration their medication or forfeit the drug completely.
NICA also encourages Congress to look beyond affordability in Part B and examine the affordability of infused products in other commercial markets. One of the most significant challenges NICA members face as providers is the implementation of “copay accumulator” and “copay maximizer” programs by certain insurance companies, including Medicare and Medicare Advantage. These programs prevent copay assistance, whether paid directly by patients or through third-party assistance, from counting toward the patient’s deductible or out-of-pocket maximum. When the copay assistance runs out, virtually none of the prescriptions filled to date have counted towards the patient’s cost-sharing responsibility, directly increasing patient out-of-pocket costs. As a result, patients are often unable to afford the treatments they need, or they delay seeking care until their financial situation becomes untenable.
For providers, this creates a ripple effect of administrative burdens. When copay accumulator adjustment programs are in effect, healthcare professionals are forced to spend significant time and resources communicating with insurance companies, reprocessing claims, and attempting to secure approvals for treatments. This takes time away from providing care and drives up operational costs for healthcare facilities, particularly those in ambulatory infusion settings that already function as cost-effective alternatives to hospital care.
Past Notice of Benefit Payment Parameters have prohibited copay accumulator adjustment programs (2020) and maximizer programs (2024), and a federal lawsuit upheld the ban on accumulators. However, the Centers for Medicare & Medicaid Services has stated that it does not intend to enforce the NBPP. These bans must be codified through Congressional action to truly protect patients from high out-of-pocket costs driven by health plan programs.
NICA encourages Congress to advance legislation – such as the Help Ensure Lower Patient (HELP) Copays Act (S.864/H.R.6423), which will help alleviate these pressures for individuals enrolled in plans under teh Affordable Care Act by ensuring that all payments made on behalf of patients count toward their cost-sharing obligations. This will allow providers to deliver care more efficiently and ensure patients can stay on their prescribed treatments without unnecessary financial obstacles.
Addressing potential Medicare program abuses that occur through Vertical Integration
The current pricing system is not serving patients who are prescribed chronic medications, and it is particularly harmful for patients on infused specialty medications that can be quite expensive due to their complexity. The business practices of pharmacy benefit managers are exacerbating the current system by driving higher out-of-pocket costs for patients, designing formularies that encourage the use of expensive drugs over lower-cost alternatives, and enforcing utilization management tools that result in delayed and even denied access to care.
Over the last decade, the PBM industry has seen considerable consolidation, which has been repeatedly documented by the Federal Trade Commission. The contractual posture that formerly existed when the insurer and the PBM were distinct entities has disappeared through mergers – Express Scripts is a subsidiary of Cigna, CVS Caremark is a subsidiary of CVS Health, and OptumRX is a UnitedHealth Group subsidiary. Historically, insurers and employers were considered clients of PBMs. However, due to extensive vertical integration within the industry, the relationship between insurers and PBMs has evolved to a mutualistic relationship. Together, these three PBMs cover over 260 million patients, amounting to control over three quarters of the prescription drug market in the United States. These three giants alone process around 80% of all prescription drug claims in the U.S. That kind of market power means they can dictate prices, squeeze out independent pharmacies, and limit patient choice while boosting their own profits.
Patients face myriads of issues as they work to secure access to the essential care they need. Barriers to care – including prior authorizations, steering to specific pharmacies or sites of care, and step therapy – are all driven by Pharmacy Benefit Managers (PBMs). PBMs dictate in-network providers, set drug formularies, determine co-pays, and even control prior authorization rules – meaning they have a massive say in which medications patients can access and where they can get them.
Meanwhile, they’re making a fortune in the process. PBMs profit at nearly every stage of the supply chain, from drug manufacturers to when patients pick up their prescriptions at the pharmacy, order their drugs from an affiliated specialty pharmacy, or receive an infusion at their provider’s office. They negotiate rebates from drugmakers (sometimes pocketing a portion of the rebate for themselves) in exchange for giving medications a preferable spot on a health plan’s formulary, their list of covered drugs. PBMs also control how much they bill insurance plans for a prescription versus what they reimburse providers for filling it, pocketing the difference, known as the “spread.” PBMs even manage Medicaid and Medicare prescription plans, using the same billing tactics with the government as they do with private insurers.
Consolidation in the market has made it difficult to negotiate with these entities. More concerning is the impact on patients, who find themselves vulnerable when their insurance providers and PBMs prioritize profits over patient savings. While PBMs excel at securing discounts, these cost reductions rarely translate into lower out-of-pocket expenses for patients. The drug pricing and premium trends over the last decade demonstrate that whatever savings PBMs negotiate are mostly absorbed by the PBMs themselves – not the patient. In fact, for every rebated dollar, the list price of the medication increases by $1.17. That hurts the patient, who typically pays coinsurance on the list price before rebates are applied.
Some manufacturers offer significant rebates for their medications. Unfortunately, most price concessions do not translate into savings for plans or patients, but are retained by the PBM itself. Thus, these rebates currently fail to have the full impact on patient out-of-pocket costs. Instead, NICA supports policies that allow these rebates to be passed on directly to the patient so they experience immediate savings at the point of sale.
Several “transparent” PBMs have disrupted the market by adjusting their fee structures to collect a flat dollar amount instead of a percentage of the drug’s list price. This removes the incentive for PBMs to prefer high-cost drugs over lower cost medications simply due to the PBM’s percentage-based compensation. NICA supports policies that require PBMs to remove coverage determinations and formulary placement from the PBM’s fee structure and instead base compensation on flat dollar amounts.
It’s important to note that the PBM compensation model is evolving. As policymakers and plan sponsors restrict traditional rebates and spread pricing, PBMs are increasingly relying on administrative, clinical, data, formulary-management, and other service fees. Although bona fide service fees do not necessarily reduce ASP, the proliferation of opaque or rebate-like fees makes it increasingly difficult to determine where revenue is generated and whether savings are reaching patients. These developments underscore the need for comprehensive transparency requirements covering rebates, fees, price concession, and payments among PBMs, their affiliated entities, and health plans.
It is very clear that PBMs and their vertically integrated subsidiaries operate in a vacuum in which none of the other parties – including ambulatory infusion centers – have access to information on how these drug pricing decisions are made. With an entirely consolidated vertical supply chain, tracing money within the business model becomes nearly impossible. Improved reporting and transparency are necessary to improve our understanding of drug prices and should be included within any PBM reform package.
This is why comprehensive PBM reform is critical. Congress took important first steps in curbing these abusive practices through the Consolidated Appropriations Act of 2026, which delinked the list price of the drug from PBM compensation for Medicare Part D and also required rebates to be passed through to the health plan sponsor for ERISA plans. However, further action is required by Congress to address these abuses for all beneficiaries, which have been caused by vertical integration.
NICA urges Congress to address these harmful and anticompetitive business practices and protect patients who deserve lower out-of-pocket costs, greater drug access and improved transparency. NICA supports several policies that address the vertical integration and abusive practices of PBMs, including:
- Expanding delinking beyond Medicare Part D and requiring delinking for ERISA plans (H.R.2214)
- Expanding rebate pass through beyond employer sponsored plans and requiring rebate pass through to the patient in Medicare Part D (S.2770)
NICA encourages Congress to continue to reign in these abusive practices by advancing additional PBM reforms beyond the Consolidated Appropriations Act of 2026.
Impact of the MFP on Physician Add-on Payments in Part B
Non-hospital, community-based infusion practices source their medications through “buy-and-bill” in which the medical practice purchases medications in advance and later bills the health plan for the medication once administered to the patient. Currently, the cost of these medications is based on the Average Sales Price (ASP), plus a six percent add-on payment which allows our members to account for acquisition costs, albeit under incredibly slim margins. However, according to the CY2026 Medicare Physician Fee Schedule, provider reimbursement for negotiated drugs will be calculated based on the Maximum Fair Price (MFP) plus a six percent add-on, based on the lower MFP.
NICA has repeatedly expressed concerns about this new calculation, which according to a recent Avalere study, could decrease the Part B add-on payment by 42-61% in Medicare and could cut reimbursement by 12-18% in the commercial market. Applying the MFP to additional drugs beyond the maximum number outlined in the law will exacerbate the impact of this underwater reimbursement for infusion centers, making it untenable for our members to provide these critical services to their patients.
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Office-based and ambulatory infusion centers play a key role as the most efficient setting for drug administration, compared to hospital outpatient departments and, in many cases, even compared to the home. Thus, it is clearly beneficial to advance policies that support our nation’s in-office drug administration capacity to further Congress and the Administration’s goals to reduce the overall cost of prescription medications for both the federal government and for patients.
Thank you for the opportunity to comment on this important issue. We would welcome the opportunity to connect with you if we can provide any other information about our concerns. Please do not hesitate to contact me, should you have any questions or wish to further discuss this issue: [email protected]
Sincerely,
Brian Nyquist, MPH
Chief Executive Officer
National Infusion Center Association
References
- Federal Trade Commission, “Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies” (July 2024).
- Health Affairs, Health Policy Brief, “Pharmacy Benefit Managers” (Sept. 14, 2017).
- The Association Between Drug Rebates and List Prices, Neeraj Sood, PhD, Rocio Ribero, PhD, Martha Ryan, and Karen Van Nuys, PhD, University of Southern California, Leonard D. Schaeffer Center for Health Policy & Economics (Feb. 11 2020)
- Annals of Health Law, “Squeezing the Middlemen: Ending Underhanded Dealing in the Pharmacy Benefit Management Industry Through Regulation” 20 Annals of Health Law 77, 82 (2011).
- Avalere Health. “Commercial Spillover Impact of Part B Negotiations on Physicians.” September 2024.
