New era of US drug pricing is arriving in 2026, say Simon-Kucher experts

This year will see a significant shift in how drugs launch, grow, and defend value in the United States, according to a thought piece from Simon-Kucher partners Allison Dupuy, PhD, and Jessica Cortez.

In the article – “Policy stacking and system logic” – Dupuy and Cortez explain that drugmakers can no longer plan pricing across Medicare, Medicaid, and 340B as if they are separate channels. This is because 2026 has multiple effective dates converging, and because policymakers are building ways to observe and enforce interactions with more precision.

The Simon-Kucher healthcare pricing experts outline six intersections that are tightening the system:

1. Concession topology

The first inflection point concerns how value is delivered in Medicaid and whether it is structured to spill across programs. The “Generous" model (Generating cost reductions for US Medicaid) uses Centers for Medicare & Medicaid Services (CMS)-led negotiation and supplemental rebates with states to align Medicaid net prices with international benchmarks for outpatient drugs.

2. Best Price and average sales price (ASP) risk concentrate in commercial leakage

The “Generous” model sharpens the contrast with the risk center of commercial constructs that leak unintended price signals. In an a more observable system, Best Price is less likely to be tripped by a headline discount than by sloppy mechanics or patient affordability designs that aren’t cleanly segregated.

3. Unit-level truth arrives in Part D

Starting on January 1, 340B units have to be excluded from Medicare Part D inflation rebate calculations – reducing inflation-rebate exposure while forcing end-to-end traceability. This requirement moves the system toward less ambiguous unit-level recognition.

4. 340B shifts from front-end discounting to settlement

The Health Resources and Services Administration’s 340B Rebate Model Pilot, which is currently paused by litigation, is another directional signal that the economics of 340B will increasingly hinge on segregation, settlement, and auditability.

5. Acquisition cost becomes an input, not an argument

The CMS’ Outpatient Prospective Payment System Drug Acquisition Cost Survey (due March 31) collects National Drug Code-level, net-of-rebates outpatient drug acquisition costs to turn “spread” into a measurable dataset that can be modeled.

6. Most-favored nation (MFN)-style benchmarking and next-gen models move into Medicare’s baseline

Proposed models such as the Global Benchmark for Efficient Drug Pricing (Globe) would assess rebates when US drug prices exceed those in economically comparable countries – importing MFN-style pressure into Medicare lanes.

“The implication for manufacturers is clear: US drug pricing strategy can’t be optimized one program at a time,” Dupuy and Cortez conclude. “The ‘so what’ is practical: you need to design and test concessions, units, and channels for how they travel across programs before they show up as higher rebates, tighter ceilings, or distorted reimbursement.”