Page 92
92
Section A. Annual Percentage Increase in Consumer Price Index (CPI) Annual Percentage Increase in Consumer Price Index, September (September CPI) Section 1860D-14(a)(4) of the Act requires CMS to use the annual percentage increase in the CPI for the 12-month period ending in September 2025 to update the maximum copayments up to the annual OOP threshold for full-benefit dually eligible beneficiaries with incomes not exceeding 100 percent of the FPL for CY 2026. These copayments are increased from $1.60 per generic, preferred drug that is a multi-source drug, or biosimilar, and from $4.80 for all other drugs in CY 2025 and rounded to the nearest multiple of $0.05 and $0.10 respectively.21 Section B. Calculation Methodology Annual Percentage Increase in Average Expenditures for Part D Drugs per Eligible Beneficiary (API) For contract years 2006 and 2007, the APIs, as defined in section 1860D-2(b)(6) of the Act, were based on the National Health Expenditure (NHE) prescription drug per capita estimates because sufficient Part D program data was not available. Beginning with contract year 2008, the APIs are based on Part D program data. For the CY 2026 benefit parameters, Part D program data will be used to calculate the annual percentage trend as follows: 𝐴𝑢𝑔𝑢𝑠𝑡 2024 −𝐽𝑢𝑙𝑦 2025 𝐴𝑢𝑔𝑢𝑠𝑡 2023 −𝐽𝑢𝑙𝑦 2024 = $5,566.70 $5,267.07 = 1.0569 In the formula, the average per capita cost for August 2023 – July 2024 is calculated from actual Part D PDE data, and the average per capita cost for August 2024 – July 2025 is calculated based on actual Part D PDE data for prescription drug claims with service dates from August 2024 – December 2024 and projected through July 2025. The 2026 benefit parameters reflect the 2025 annual percentage trend, as well as updates for revision to prior year estimates for API. Based on updated NHE prescription per capita costs and PDE data, the annual percentage increases are now calculated as summarized by Table V-3. Table V-3. Revised Prior Years’ Annual Percentage Trends Year Prior Estimates of Annual Percentage Trend Revised Annual Percentage Trend 2006 7.30% 7.30% 2007 5.92% 5.92% 2008 4.69% 4.69%
21 Per section 1860D-14(a)(4)(A) of the Act, the copayments are increased from the unrounded 2025 values of $1.59 for multi- source generic or preferred drugs, and $4.77 for all other drugs.