2026 Specialty Drug Pricing: What Infusion Practices Need to Know Before January 1st

2026 Specialty Drug Pricing: What Infusion Practices Need to Know Before January 1st

January 1, 2026 brings the biggest shift in specialty drug economics in years. Medicare's first-ever negotiated drug prices take effect, including Stelara (66% reduction) and Enbrel (67% reduction).[1] Combined with the new $2,100 Part D out-of-pocket cap[2] and growing biosimilar competition (Stelara biosimilars now offer 80-90% discounts[3]), practices managing infusions and injections face significant changes to acquisition costs, reimbursement, and patient affordability.

Background: What Happened to Drug Prices in 2025?

Before looking ahead to 2026, it's worth understanding the 2025 landscape. Pharmaceutical manufacturers raised list prices on more than 250 branded drugs in January 2025, according to data from healthcare research firm 3 Axis Advisors reported by Reuters.[4] The median price increase was 4.5%, consistent with recent years and well below the 9% median increases seen a decade ago.[4]

Notable increases that affected specialty practices in 2025:

  • Pfizer: Raised prices on 60+ drugs including Xeljanz (rheumatology), Ibrance (oncology), and Nurtec (neurology) by 3-5%[4]
  • Bristol Myers Squibb: CAR-T therapies Abecma and Breyanzi increased 6% and 9% respectively[4]
  • Sanofi: Vaccine portfolio increased 2.9-9%[4]

What this meant for practices: For buy-and-bill drugs, list price increases affect inventory carrying costs and may create a temporary margin gap before ASP-based reimbursement adjusts (typically a 2-quarter lag).[5]

How Do Stelara Biosimilar Launches Affect GI and Rheumatology Practices?

Nine biosimilar versions of Stelara (ustekinumab) have now launched in the U.S. market, with list price discounts ranging from 5% to 90% below the reference product.[3] All approved Stelara biosimilars became interchangeable with the reference product as of April 2025, when Amgen's Wezlana exclusivity period ended.[3] This creates significant opportunities, and complexity, for practices managing IBD, psoriasis, and psoriatic arthritis patients.

Key Stelara Biosimilar Launches:

Biosimilar Manufacturer Launch Discount vs. Stelara
Wezlana Amgen January 2025 Varies by PBM [6]
Selarsdi Teva/Alvotech February 2025 85% [7]
Pyzchiva Sandoz February 2025 80% [7]
Yesintek Biocon 2025 90% [7]

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What this means for practices: Lower acquisition costs for ustekinumab biosimilars could improve buy-and-bill margins for GI and rheumatology practices. However, formulary placement varies significantly by PBM.[3] Practices should verify biosimilar coverage with each payer and consider the implications for both IV (loading dose) and subcutaneous (maintenance) administration routes.

The Big Change: Medicare Negotiated Prices Take Effect January 1, 2026

This is the headline for 2026. The Inflation Reduction Act authorized Medicare to negotiate prices for high-spend drugs, and those negotiated Maximum Fair Prices take effect January 1, 2026.[1] Two of the 10 drugs in this first round—Stelara and Enbrel, are commonly administered via infusion or injection in specialty practices.

Negotiated Prices for Infused/Injected Drugs:

Drug Conditions Treated Specialties Discount [1]
Stelara Crohn's, UC, Psoriasis GI, Rheum, Derm ~66%
Enbrel RA, Psoriasis, AS Rheum, Derm ~67%

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CMS estimates that if these negotiated prices had been in effect in 2023, Medicare would have saved $6 billion across all 10 drugs.[1] Medicare beneficiaries using these drugs are projected to save $1.5 billion in out-of-pocket costs when prices take effect in 2026.[1] Learn how these drug pricing changes affect patient out-of-pocket costs and coverage.

What this means for practices in 2026: Stelara is now subject to both biosimilar competition and Medicare negotiated pricing. Practices administering Stelara should evaluate how both factors affect acquisition costs and reimbursement starting January 1. The Medicare $2,100 out-of-pocket cap (up from $2,000 in 2025) may also reduce patient payment barriers for high-cost infusions.[2]

Which Part B Drugs Have Reduced Coinsurance Under the IRA?

The Inflation Reduction Act requires drug manufacturers to pay rebates to Medicare when drug prices increase faster than inflation. As a result, Medicare beneficiaries pay reduced coinsurance on 64 Part B drugs as of Q1 2025.[8] These are physician-administered drugs, many of which are infused or injected in specialty practices.

For Medicare patients receiving infusions of affected drugs, the coinsurance is calculated on an inflation-adjusted (lower) payment amount rather than the actual ASP.[8] This can result in meaningful out-of-pocket savings for patients and may reduce collection risk for practices.

Preparing Your Practice for 2026

  1. Review Stelara and Enbrel economics now. Medicare negotiated prices take effect January 1, 2026.[1] If you administer either drug, verify how the new pricing affects your acquisition costs and reimbursement.
  1. Evaluate biosimilar options. Stelara biosimilars with 80-90% list price discounts may offer improved buy-and-bill margins.[3] Confirm formulary placement and patient eligibility before switching.
  1. Update patient financial counseling. The $2,100 out-of-pocket cap[2] and reduced coinsurance on 64+ Part B drugs[8] may change what patients owe. Make sure your front-office team knows the new numbers.
  1. Monitor CMS ASP files quarterly. Negotiated prices and biosimilar competition will affect ASP-based reimbursement throughout 2026.[5] Stay current to protect your margins.

Learn how to implement in-office infusion to capture buy-and-bill revenue opportunities.

How OnePulse Connect Helps Practices Navigate Drug Pricing Complexity

Managing drug acquisition, reimbursement, and billing in a shifting pricing environment requires real-time visibility and operational control. OnePulse Connect provides specialty practices with integrated solutions for:

  • Buy-and-bill management: Optimize drug purchasing, track acquisition costs, and ensure accurate billing
  • Inventory management: Monitor drug inventory, reduce waste, and maintain DSCSA compliance
  • Benefits verification: Identify optimal billing pathways (medical vs. pharmacy benefit) for each patient
  • In-office infusion: Turnkey infusion program with nursing, compliance, and patient engagement

Schedule a Consultative Meeting

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About Elevate Health Technologies

Elevate Health Technologies is committed to making healthcare better for everyone. We collaborate with healthcare providers, patients, pharmaceutical manufacturers, and payers to deliver innovative technologies that truly make a difference.

OnePulse Connect empowers healthcare practices by optimizing efficiency and streamlining care, whether through buy-and-bill management, inventory tracking, medically integrated dispensing, or in-office infusion services. Our tailored approach delivers deep data insights, advanced analytics, and dynamic patient engagement platforms.

Together, we move as One Pulse, driving smarter, faster, and more connected health technologies for improved outcomes and better patient experiences.

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References

[1] Kaiser Family Foundation. "FAQs about the Inflation Reduction Act's Medicare Drug Price Negotiation Program." KFF.org. Updated August 9, 2025. Accessed December 2025. https://www.kff.org/medicare/faqs-about-the-inflation-reduction-acts-medicare-drug-price-negotiation-program/

[2] Norris, Louise. "How will my Medicare prescription drug costs in 2026 compare with 2025?" MedicareResources.org. December 2025. Accessed December 2025. https://www.medicareresources.org/faqs/how-will-my-medicare-prescription-drug-costs-change-next-year/

[3] Fein, Adam J. "The Stelara Biosimilar Price War: How PBM-Affiliated Private Labels Are Reshaping the Market." Drug Channels. July 2025. Accessed December 2025. https://www.drugchannels.net/2025/07/the-stelara-biosimilar-price-war-how.html

[4] Erman, Michael. "Drugmakers to raise U.S. prices on over 250 branded medications starting Jan. 1." Reuters, via Becker's Hospital Review. December 31, 2024. Accessed December 2025. https://www.beckershospitalreview.com/pharmacy/drugmakers-plan-price-hikes-for-250-medications-in-2025-reuters/

[5] Centers for Medicare & Medicaid Services. "Medicare Part B Drug Average Sales Price." CMS.gov. Updated 2025. Accessed December 2025. https://www.cms.gov/medicare/payment/fee-for-service-providers/part-b-drugs/average-drug-sales-price

[6] Jeremias, Skylar. "Welcome Wezlana: The First Stelara Biosimilar to Launch in the US." Center for Biosimilars. January 31, 2025. Accessed December 2025. https://www.centerforbiosimilars.com/view/welcome-wezlana-the-first-stelara-biosimilar-to-launch-in-the-us

[7] Managed Healthcare Executive. "Updated: Two More Stelara Biosimilars Launch, Including One that is 90% Off Stelara." December 2025. Accessed December 2025. https://www.managedhealthcareexecutive.com/view/two-more-stelara-biosimilars-launch

[8] Centers for Medicare & Medicaid Services. "Reduced Coinsurance for Certain Part B Rebatable Drugs, January 1 – March 31, 2025." CMS.gov. 2024. Accessed December 2025. https://www.cms.gov/files/document/reduced-coinsurance-certain-part-b-rebatable-drugs-january-1-march-31-2025.pdf

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