Newsletter · · Ashutosh Agarwal

340B Rebates Are Back, Aimed at IRA Negotiated Drugs - Drug Pricing & IRA Round 2 Weekly - Week of August 10 – August 17, 2026

Drug-pricing and IRA policy podcast intelligence for the week of August 10 to 17, 2026. HRSA reinstated a 340B rebate model aimed squarely at the drugs Medicare has negotiated under the IRA, a bipartisan Senate group dropped the 97-page SUSTAIN 340B Act, and the AstraZeneca and Bristol-Myers merger rumor got read as a patent-cliff scramble.

Drug Pricing & IRA Round 2 Weekly

Week of August 10 – August 17, 2026: 340B Rebates Are Back, Aimed at IRA Negotiated Drugs

TL;DR

  • The single biggest development of the week has nothing to do with the IRA's headline negotiation program and everything to do with its plumbing. The federal health agency that runs the 340B discount program (HRSA) has issued a formal notice bringing back a "rebate model" starting January 1, 2027, and it is aimed squarely at the exact drugs Medicare has been negotiating under the IRA: the 10 drugs whose new prices take effect in 2026 and the 15 more coming in 2027. This is the collision of two federal price-cut programs on the same molecules, and it changes how hospitals get their discounts on those drugs from an instant point-of-sale cut to a pay-first, claim-it-back-later rebate. Two 340B compliance consultants walked through it in unusual operational detail. (340B Unscripted, "Ep 97 | HRSA 340B Rebate Model & SUSTAIN 340B Act," August 10, 2026)

  • In the same week, Congress finally put real legislative text on the table. A bipartisan group of six senators dropped the SUSTAIN 340B Act, 97 pages of the first serious attempt to overhaul the 340B program. For hospitals it is a mixed bag: big wins (locked-in protections for pharmacy access, and a hard sunset on the rebate model after one year) sit next to real threats (new rules that could disqualify standalone infusion visits, a three-year waiting period before newly built clinics can use 340B, and a $50 million annual fee). The consultants' honest read on its odds this year: under 5%, but roughly 20–25% it sneaks into a year-end spending package, and a strong chance it comes back in 2027. (340B Unscripted)

  • The AstraZeneca and Bristol-Myers merger rumor got a real pharma-industry read, and it is a patent-cliff story with the IRA hiding in it. A specialist biopharma show laid out why Bristol-Myers is the one that needs this deal: its two biggest drugs, the blood thinner Eliquis and the cancer immunotherapy Opdivo, together made up half of the company's roughly $48 billion in 2025 sales, and both fall off patent in 2028. Eliquis is also one of the very first drugs Medicare negotiated under the IRA. So the "biggest merger ever" chatter is, at its core, a scramble to backfill revenue that patent expiry and government price cuts are about to drain. Analysts and portfolio managers mostly hated the idea. (BioSpace, "Rumors of biggest pharma merger ever drop amid Q2 earnings, contentious FDA adcomms," August 11, 2026; Market Maker, "Why Sainsbury's Sold Argos (It's Not What You Think)," August 10, 2026)

  • The pressure on the drug middlemen keeps building. Fresh survey data this week showed 46% of large employers have already moved off the three biggest pharmacy-benefit managers (CVS Caremark, OptumRx, and Express Scripts), and more than half of those still using a big-three plan to switch within three years, even as they brace for a 7.7% jump in health costs next year. That is the read-through everyone with CVS, Cigna, or UnitedHealth in the book should be watching. (Pharmacy Podcast Network, "The Value of a Trusted Wholesaler & Cole's Act Update | TWIRx," August 14, 2026; Chip Stock Investor Podcast, "The Healthcare Bubble No One's Talking About (with Dr. Bradley Gibson)," August 12, 2026)

  • Where the week's action was. The movement came in the adjacent plumbing, 340B, PBMs, and M&A, rather than at the negotiation program's front door. The Round 2 negotiation itself (the 2027 talks, 2028 prices), the 2028 list adding physician-administered Part B drugs, the "pill penalty"/EPIC Act fix, the Most Favored Nation deals, and the Lilly retatrutide court fight all stand where last week left them.

What's new

Ranked by how much a hedge-fund book can act on it.

1. The 340B rebate model is back, and it targets the same drugs the IRA is negotiating

Start with what 340B is, because it sits underneath a huge share of US hospital economics. Under the 340B program, hospitals and clinics that serve a lot of low-income patients get to buy outpatient drugs at a deep federal discount, then bill insurers at normal rates and keep the spread to fund care. It is, in effect, a multi-billion-dollar subsidy delivered through the pharmacy counter.

For decades, that discount happened at the point of sale: the hospital simply bought the drug cheap. This week, HRSA (the agency that runs 340B) issued a notice reinstating a "rebate model" instead: hospitals will now buy certain drugs at the full list price (what the industry calls WAC, the wholesale acquisition cost), then file a claim and wait for the manufacturer to send the discount back as a rebate. The two consultants on 340B Unscripted, Greg Wilson and Rob Nahoopii, who advise hospitals on running these programs and are about as close to operators and insiders as this beat gets, did not sugarcoat it: "This is a major change in how the 340B program works." (340B Unscripted)

Here is the part that ties it directly to this newsletter's core subject. The rebate model does not apply to all drugs. It applies only to the drugs Medicare has selected for IRA price negotiation: the 10 drugs whose negotiated prices start in 2026 and the 15 more arriving in 2027, roughly 25 molecules in total (a couple may drop off). In other words, the government is layering its 340B discount machinery directly on top of its IRA negotiation machinery, on the same handful of blockbuster drugs. Hospitals now have to front the cash for these expensive products and chase the rebate afterward, uploading claims data within 45 days of dispensing, with manufacturers able to deny rebate claims they judge ineligible.

Why this got reinstated matters too: HRSA tried the same thing last year, a federal court said the agency "didn't do enough analysis and moved too fast," and the whole thing was suspended at the start of 2026. HRSA is now bringing it back as a "pilot," and, crucially, this notice is not open for public comment. Hospitals do not get to weigh in; they just have to comply.

The calendar is tight and worth marking:

  • Manufacturers must submit their rebate proposals to HRSA by August 24.
  • HRSA has 30 days to approve them, by September 24.
  • Approved manufacturers must give hospitals 90 days' notice by October 1 to go live on January 1, 2027.

So by October 1 we will know exactly which manufacturers are switching their negotiated drugs to the rebate model on January 1. The consultants expect a messy split, with some manufacturers ready and one or two not, meaning hospitals may have to run two different discount processes side by side for these drugs.

And that is not the only 340B squeeze landing at once. A separate Medicare rule (the OPPS proposed rule, comments due August 31) would slash what hospitals get paid for Part B 340B drugs to ASP minus 33.4%, down from ASP plus 6% today, a brutal swing for the disproportionate-share, rural referral, and urban sole-community hospitals it hits. A third rule would force hospitals to start uploading their Medicare Part D claims into a new federal data repository from January 1, 2027. As Nahoopii put it, half out of breath: "There's a lot going on and I think you have to start working on what you can today." (340B Unscripted)

Why it matters for a book: this is the most concrete, dated policy action of the week, and it is the clearest example yet of the IRA's negotiated-drug list becoming the anchor for other federal price-cut programs. For hospital operators, it is a working-capital and margin hit (pay list price, wait for the rebate, absorb a Part B payment cut). For the manufacturers of the roughly 25 negotiated drugs, it adds another layer of administrative friction and rebate discretion on top of the IRA cut itself. Watch October 1.

2. Congress puts 97 pages on the table: the SUSTAIN 340B Act

The same week the rebate notice dropped, a bipartisan "Gang of Six" senators introduced the SUSTAIN 340B Act, the first genuinely comprehensive attempt to rewrite the program, something the 340B world has been waiting years to see. Wilson and Nahoopii went through it section by section. Their framing was that it reads "a lot like a divorce decree": nobody gets everything, but most people can live with it. (340B Unscripted)

The wins for hospitals:

  • It would codify contract-pharmacy protections, stopping drugmakers from restricting hospitals' ability to fill 340B prescriptions through outside pharmacies. The consultants called this "a big win for the 340B provider group."
  • It would kill the rebate model after one year, mandating that the 340B discount go back to being a point-of-sale cut through a neutral clearinghouse. As Nahoopii said, "I'm glad that they finally said, look, we're getting rid of this."
  • It adds reimbursement protections against PBMs, barring pharmacy-benefit managers from paying 340B providers less, or forcing them to flag 340B transactions, just because they are 340B.

The threats for hospitals:

  • It would exclude standalone infusion visits, where a patient comes in only to get a drug infused with no preceding medical visit, from 340B eligibility. The consultants flagged this as a serious blow, especially to "community hospitals and smaller hospitals," whose infusion centers currently qualify.
  • It imposes a three-year waiting period before a newly built or newly acquired clinic can access 340B pricing (with a 180-day hardship exception) and, more alarmingly, a retroactive look-back that would re-test already-registered clinics against the new rules, with no grandfathering. The consultants called the retroactive piece "insane" and "bad policy."
  • It adds a $50 million annual user fee on covered entities and, for the first time, civil monetary penalties for compliance failures.

Does it have legs? The consultants' blunt handicapping: "less than 5%" it passes this year, because a third of the sponsoring senators are heading into re-election and the entire House is up. But roughly 20–25% it gets folded into a year-end health-extenders or omnibus spending package during the lame-duck session, and "I think this comes back and it comes back strong in 2027" with the new Congress. (340B Unscripted)

Why it matters for a book: 340B reform is now a live, bipartisan legislative object, not a wish-list. The direction of travel, codified pharmacy protections in exchange for tighter eligibility, transparency, fees, and penalties, reshapes hospital drug economics and, indirectly, the volumes and channels drugmakers sell into. Low odds this year, but a real 2027 catalyst to start pricing.

3. The "biggest merger ever" is a patent-cliff defense with the IRA underneath it

Last week the Financial Times reported AstraZeneca and Bristol-Myers Squibb had held merger talks. This week a specialist biopharma newsroom, BioSpace, gave it the industry read on its weekly show. Hosts Jeff Axt, Annalee Armstrong, and Gabby are trade journalists, informed pundits rather than company insiders, but they added the analytical layer the mainstream coverage missed. (BioSpace)

The scale: Bristol-Myers carries a market value just over $130 billion, AstraZeneca closer to $200 billion, and a combination would create a roughly $400 billion company, "the largest pharma company of all time." BMS shares rose on the news; AstraZeneca's fell about 7%.

The reason BMS gains more is the reason this belongs in a drug-pricing letter. As Armstrong explained, "BMS looks to gain a lot more… largely because of its 2028 patent cliffs for blood thinner Eliquis and immunotherapy Opdivo, which together account for half of BMS's 2025 global sales," roughly $48 billion in total revenue, with about half of that from those two drugs alone. Eliquis is not just a patent-cliff drug; it is one of the very first drugs Medicare negotiated under the IRA. So Bristol-Myers is staring at patent expiry and government price cuts hitting its two biggest products at essentially the same moment, and analysts at William Blair noted that "additional bolt-on acquisitions may prove difficult to offset the decline of legacy products." Analysts at Leerink called the deal's rationale "very mixed," especially for AstraZeneca.

The wall in the way is antitrust, and specifically oncology: the two companies' immunotherapies (BMS's Opdivo and AstraZeneca's Imfinzi) compete directly, and a merger would create what BioSpace called "the deepest bench in oncology in the world."

The UK finance show Market Maker captured how badly the buy-side received it, quoting named investors. Portfolio manager Marcus Manns of Union Investment said "the deal makes neither strategic nor financial sense." Lucas Liu of ATG Healthcare was harsher: "I'm not a big fan of mega mergers. It kills innovation and agility and would be growth dilutive for AstraZeneca in the near term." One unnamed source called it "the equivalent of the World Cup for-profit fundraise in terms of its strategic misstep and terrible communication." The hosts' verdict: AstraZeneca shares fell about 9%, the deal "is not going to get through antitrust unless it's AZ acquiring Bristol-Myers Squibb," and "this isn't going anywhere." (Market Maker)

Worth connecting to last week's tell: on CNBC last week the chatter was that any deal this size would have to "lead with… lowering drug prices" to get approved. That is the drug-pricing hook. If this ever advances, expect price concessions to be central to the antitrust pitch.

Why it matters for a book: the merger itself looks unlikely, but the logic is the trade. Bristol-Myers is the clearest case of a big-cap whose earnings power is exposed to the exact double-hit this letter tracks, patent cliff plus IRA negotiation, on Eliquis, and management's willingness to explore a $400 billion Hail Mary tells you how urgent that revenue hole is. AstraZeneca weakness on the rumor is a sentiment event, not a fundamental one.

4. The PBM squeeze gets fresh employer data

The read-through to the drug middlemen, the pharmacy-benefit managers owned by the big insurers, got new numbers this week. On the Pharmacy Podcast Network's This Week in Pharmacy, host Todd Eury (a longtime PBM-reform advocate, so read him as an opinionated pundit) cited an August 12 Axios report on a survey of 408 employers by the National Alliance of Healthcare Purchaser Coalitions: nearly half, 46%, are already using a PBM other than the big three (CVS Caremark, OptumRx, and Express Scripts); 56% of those still on a big-three plan are considering a switch within three years; and employers project a 7.7% rise in health costs next year. The episode also tracked state-level reform, Wisconsin's Cole's Act, set for reintroduction in 2027, which would ban mid-year formulary changes and below-cost pharmacy reimbursement, and noted federal PBM reform that "passed out of committee 40 to 2." (Pharmacy Podcast Network)

For the mechanics behind why this matters, the Chip Stock Investor Podcast ran a genuinely useful walkthrough of how the insurer-PBM machine actually makes money, with Dr. Bradley Gibson (a physician, an expert voice rather than a company insider). His core point: because federal rules cap how much of your premium an insurer can keep as profit (they "can only keep 15 to 20 percent"), the real money migrated into the unregulated PBM arms, where rebates on drugs are "decoupled from cost." He laid out just how vertically integrated the giants have become, with UnitedHealth's Optum now directly employing about 90,000 doctors, "just under 10% of the actual physician workforce in America," and flagged the fragility of that model: United's push into value-based contracts flipped from "making $7 billion to losing just under a billion dollars" in 2025 when patients used more care than the math assumed. (Chip Stock Investor Podcast)

Why it matters for a book: the structural story for CVS, Cigna, and UnitedHealth is a slow bleed of employer clients away from the big-three PBMs, layered on regulatory heat at both state and federal levels, while the IRA's own Part D changes tighten the drug-plan economics on the other side. None of this week's episodes put a franchise-level number on it, but the direction is unambiguous.

5. Odds and ends worth a line

AstraZeneca keeps planting roots in the US. A Charlottesville, Virginia local show reported the company has now pinned its planned US global headquarters there at 3,600 direct and indirect jobs, including 600–1,000 high-paying roles starting at $125,000 a year, fully up and running in early 2029. It is a local-news item, not pharma analysis, but it is a concrete data point for the onshoring theme, consistent with AstraZeneca's own line last week that it feels "more blessed than many" on tariff exposure because its supply chain is already distributed. Building in the US is exactly what you do when Most Favored Nation pricing and tariff threats make American manufacturing a hedge. (The I Love CVille Show, "AstraZeneca Will Create 3600 New CVille Jobs…," August 11, 2026)

A demand tell from the Lilly universe. A markets-recap show (Telltales, note this one is produced entirely with AI-generated voices, so treat it as synthesized commentary rather than a named human's view) flagged that Eli Lilly, fresh off a Q2 with revenue around $23 billion (up 48%), has sued six companies over black-market sales of retatrutide, a drug it has not even launched yet. As the show put it, "suing counterfeiters of a product you cannot buy is its own kind of demand data." The same recap noted Lilly's oral GLP-1 pill took a first UK approval with weekly prescriptions at a new high near 29,000. Neither is a pricing story, but both reinforce that obesity demand remains the one place pricing power still lives. (Telltales, "Weekend Update - W2633," August 16, 2026)

The debate

The argument this letter tracks, a manageable, well-modeled headwind versus a structural squeeze on US drug margins, did not get a fresh Round 2 negotiation data point this week. But the 340B news reframed it in a useful way: the fight is no longer only about the negotiation program itself. It is about how many adjacent federal programs pile onto the same drugs.

The "it's bounded and manageable" case. The negotiation program covers a defined list, 10 drugs, then 25, and companies have known the timelines for years. Even the scary-sounding 340B rebate reinstatement applies only to those same negotiated drugs, and the SUSTAIN 340B Act would kill the rebate model outright after a single year while handing hospitals real protections. The AstraZeneca and Bristol-Myers rumor, for all the drama, was panned by the very portfolio managers who own these names, hardly the behavior of a market that thinks pricing is an existential threat. And AstraZeneca is confident enough in the environment to sink a US global headquarters and thousands of jobs into Virginia. (340B Unscripted; The I Love CVille Show)

The "the squeeze compounds" case. Look at what actually happened this week. The government reinstated a discount mechanism, without public comment, that forces hospitals to front cash on the negotiated drugs and chase rebates, while simultaneously proposing to cut Part B 340B payments from ASP plus 6% to ASP minus 33.4%. That is three separate margin pressures (IRA negotiation, 340B rebate friction, and an OPPS payment cut) converging on the same molecules and the same hospital P&Ls at the same time. Bristol-Myers exploring a $400 billion merger is not a sign of confidence; it is a company facing a 2028 wall on drugs (Eliquis, Opdivo) that make up half its revenue, one of them already under IRA negotiation. And the employer flight from the big-three PBMs shows the middle of the supply chain is under its own structural strain. The pieces do not point to one clean number; they point to steady, multi-front compression. (340B Unscripted; BioSpace)

The swing factor this week is October 1. That is the date by which we will know which manufacturers of the IRA-negotiated drugs are actually flipping to the 340B rebate model on January 1. It is the first hard, dated read on how the negotiation list and the 340B program interact in practice, and a cleaner near-term signal than any of the legislative theater around it.

Stocks in play

Same discipline as prior weeks. What follows is only what the week's episodes actually support, and none of them attached a specific revenue-at-risk figure to a tracked franchise.

Bristol-Myers Squibb (BMY), the week's central name.

  • Bull: the AstraZeneca rumor put a takeout floor under the stock, and BMS shares rose on the news; its oncology franchise (Opdivo) is the strategic draw, and management has roughly $35 billion of cash to defend itself.
  • Bear: Eliquis and Opdivo together are about half of roughly $48 billion in 2025 sales and both fall off patent in 2028, with Eliquis already under IRA negotiation. Analysts warn bolt-ons "may prove difficult to offset the decline of legacy products."
  • Next catalyst / number to watch: any confirmation or collapse of the AstraZeneca talks, and whether the 2028 patent/negotiation hole gets a credible backfill plan. (BioSpace)

AstraZeneca (AZN), the pursuer, and the tariff-hedge name.

  • Bull: portfolio managers defended its "strong pipeline and organic growth outlook"; it is committing to a US global headquarters (3,600 jobs in Virginia), a real hedge against MFN and tariff risk.
  • Bear: shares fell 7–9% on the merger rumor; the buy-side called a Bristol-Myers deal "growth dilutive," strategically senseless, and badly communicated, and an oncology tie-up faces steep antitrust review.
  • Next to watch: whether management confirms, denies, or walks back the talks, and how the Virginia build-out progresses. (BioSpace; Market Maker; The I Love CVille Show)

Pfizer (PFE), the disciplined-capital name.

  • Bull: CEO Albert Bourla said the roughly $7 billion earmarked for deals is "plenty," pointed to prior bets (MetSera, CGen) executing "at light speed," and layered on another $2.5 billion of cost cuts extending its efficiency program through 2029.
  • Bear: it has far less firepower than AstraZeneca or Bristol-Myers (roughly $35 billion each), and its own franchises (Eliquis, Ibrance) sit under the same negotiation and cliff cloud; the cost-cutting "since October 2023" raises the question of how much is genuine investment versus retrenchment as COVID revenue fades.
  • Next to watch: the promised bolt-on in immunology, oncology, or obesity. (BioSpace)

Eli Lilly (LLY), still the pricing-power outlier.

  • Bull: a Q2 with revenue around $23 billion (up 48%) and a raised full-year forecast; obesity demand so strong the company is suing counterfeiters of a drug it hasn't launched, and its oral GLP-1 is scaling in the UK (about 29,000 weekly scripts).
  • Bear / uncertainty: none of this week's coverage advanced the retatrutide biologic-versus-small-molecule classification fight (and its September 24 court date) that governs how soon the IRA clock can reach Lilly's next-generation assets.
  • Next to watch: the retatrutide appeal hearing and Q1 biologics filing carried over from prior weeks. (Telltales)

CVS Health (CVS), Cigna (CI), UnitedHealth (UNH), the PBM read-through.

  • Bull: these are diversified, deeply integrated players; the underlying insurance franchises are historically "stable compounders of profitability."
  • Bear: 46% of large employers have already left the big-three PBMs and half of the rest may follow within three years; state (Cole's Act) and federal PBM reform are advancing; and UnitedHealth's 2025 value-based swing from a $7 billion profit to a roughly $1 billion loss shows how fast the integrated model can misfire.
  • Next to watch: 2027 plan-year bids and any franchise-level disclosure on PBM client retention. (Pharmacy Podcast Network; Chip Stock Investor Podcast)

JNJ, MRK, NVO, ABBV, passing mentions only this week. Merck's Q2 was noted as "pretty solid," with color on its anti-TL1A antibody, but nothing on drug-pricing exposure. Their negotiation- and MFN-exposed franchises will have to be sized from filings and Street models. (BioSpace)

Read-throughs

Hospitals and 340B providers (and the manufacturers of the negotiated drugs). This is the week's real read-through. Reinstating the rebate model on the IRA-negotiated drugs, buy at list price, chase the rebate, absorb a possible Part B payment cut to ASP minus 33.4%, is a direct working-capital and margin hit to disproportionate-share, rural referral, and urban sole-community hospitals. For the drugmakers whose products are on the list, it adds another layer of rebate administration and denial discretion on top of the negotiated price itself. And the SUSTAIN 340B Act, if it advances in 2027, would reshape which sites and encounters even qualify. (340B Unscripted)

PBMs and managed care (CVS, CI, UNH, and Part D insurers). The employer exodus from the big-three PBMs (46% already gone, 56% of the rest weighing a switch) plus advancing state and federal reform points to a structurally tighter middle of the drug supply chain, arriving at the same time the IRA's Part D redesign is squeezing drug-plan economics from the other side. The counter is that these are diversified giants with historically durable insurance profits; the risk is that the integrated PBM-plus-provider model (UnitedHealth's 90,000 employed doctors, its value-based-contract loss) is more fragile than the market assumes. (Pharmacy Podcast Network; Chip Stock Investor Podcast)

Patent cliffs meeting the negotiation list (BMY first, then the sector). Bristol-Myers is the cleanest example of the double-hit: Eliquis and Opdivo, half of revenue, both off-patent in 2028, one already IRA-negotiated. That combination is what is driving a $400 billion merger conversation. Every big-cap with a negotiated blockbuster approaching patent expiry sits on the same fault line; the differentiator is the depth of the pipeline behind it, which is exactly why the buy-side prized AstraZeneca's organic growth outlook over a defensive merger. (BioSpace)

Ex-US strategy and onshoring (AZN). AstraZeneca's US global-headquarters build in Virginia is a small but tangible sign of the onshoring hedge against Most Favored Nation pricing and tariffs. Expect more of this posture, invest visibly in US manufacturing and jobs, from large drugmakers trying to stay on the right side of the administration's pricing and trade agenda. (The I Love CVille Show)

What changed vs. last week

Last week (August 3–10) was obesity and Most Favored Nation, told through earnings: AstraZeneca's CFO confirming a signed MFN deal on the record, the Lilly retatrutide biologic-versus-pill fight with its September 24 court date, hard numbers on the Part D subsidy sunset ($255 direct subsidy), and Lilly's roughly $15 billion GLP-1 quarter. This week the story moved sideways into the adjacent plumbing, 340B, PBMs, and M&A, and away from the negotiation program's front door.

What moved:

  • 340B became the story. HRSA reinstated the rebate model, aimed specifically at the IRA-negotiated drugs, with a hard October 1 signal; a separate rule would cut Part B 340B payments to ASP minus 33.4%; and the Senate dropped the 97-page SUSTAIN 340B Act. This is a genuinely new thread and the most concrete policy action in weeks. (340B Unscripted)
  • The AstraZeneca and Bristol-Myers rumor got its industry read. Last week the deal surfaced; this week specialists and portfolio managers dissected it: the BMS patent-cliff and IRA logic on Eliquis and Opdivo, the oncology antitrust wall, and a near-uniformly negative buy-side reaction (AZN down 7–9%). (BioSpace; Market Maker)
  • The PBM read-through got fresh data, 46% of large employers off the big-three, 56% of the rest considering it, and 7.7% projected cost inflation. (Pharmacy Podcast Network)

What carried over unchanged: the IRA Round 2 negotiation itself, the 2028 Part B selected-drug list, the EPIC Act pill-penalty fix, new MFN signings, and the retatrutide court fight all stand where last week left them. The MFN and negotiation front paused; the plumbing took over.