As 2026 approaches, independent pharmacies and Medicare beneficiaries face updates that may affect drug costs, billing, and operations. Staying informed helps pharmacies support patients, comply with rules, and adapt to reimbursement changes. Below is a breakdown of confirmed changes, evolving areas, and practical steps to prepare.
Confirmed Medicare Changes for 2026
Below is a summary of the changes already finalized by CMS and other authorities that will take effect in 2026 and their potential impact on pharmacies and patients that pharmacy teams should consider when counseling patients.
Part D out-of-pocket cap
In 2026, the Part D out-of-pocket maximum will increase from $2,000 to $2,100.
Why it matters: Patients may reach catastrophic coverage slightly faster, which can affect their out-of-pocket spending.
What to do: Update cost estimates when counseling patients so they have an accurate picture of their potential expenses.
Part D deductible ceiling
The maximum deductible for Part D plans will rise to $615.
Why it matters: Patients could face higher upfront costs before benefits begin, which may affect medication adherence.
What to do: Review plan datasheets with patients to provide clear guidance on their deductible and when coverage phases kick in.
Automatic renewal for Prescription Payment Plans (MPPP)
Medicare Prescription Payment Plans will automatically renew each year unless the patient opts out.
Why it matters: Patients may not realize they are automatically enrolled, leading to unexpected charges.
What to do: Check which patients are in MPPP and establish a process for handling opt-outs promptly.
Part D premium adjustments
CMS is modifying Part D premiums by reducing the uniform base beneficiary premium reduction from $15 to $10 and expanding allowable year-over-year premium increases from $35 to $50.
Why it matters: Plans may raise premiums slightly more aggressively, which could impact patient affordability.
What to do: Monitor patient plans for premium changes and counsel patients on potential cost impacts.
Medicare drug price negotiation
The first set of negotiated drug prices under the Inflation Reduction Act will take effect for high-spend drugs.
Why it matters: Drug costs may change, affecting reimbursements and patient billing.
What to do: Update contracting, reimbursement, and claims systems to reflect the new negotiated rates.
While most of these changes aren’t dramatic on their own, together they will affect how pharmacies handle payments, benefits, and daily operations. Pharmacies that prepare early will stay ahead and keep their patients happier in 2026.
Evolving areas of Medicare Part D
Even though many changes are already finalized, several important policies remain in flux or subject to interpretation, guidance, or potential future revision. Pharmacy teams should monitor these:
Prior authorization/utilization management guardrails
In the proposed (but not finalized) rule, CMS sought to clarify and limit the use of utilization management, internal coverage criteria, and introduce “guardrails” for AI use in MA/Part D plan decisions (to ensure equitable access). However, the final rule did not codify all of these.
Why it matters: If CMS later introduces stricter limits, pharmacy prior authorization burden could lighten. Conversely, maintaining the status quo could exacerbate administrative burden on independents.
Rebate timing and cash flow risk
IOne real concern among independent pharmacies is the lag between dispensing negotiated-price drugs and receipt of manufacturer rebates. Some pharmacies are debating whether to stock certain negotiated‐price drugs at all, due to capital outlay and rebate delay risk.
What to watch: CMS or Congress could consider cash-flow alleviation mechanisms (advance payments, bridging funds, or earlier rebates)
MA network adequacy and directory enforcement
While MA plans must now submit directory changes within 30 days and attest annually to directory accuracy, CMS declined to require attestation that directory data exactly matches internal network data during network adequacy checks.
Risk point: Network discrepancies, especially unnoticed ones, could lead to patient complaints or “access” challenges that may not be immediately corrected.
Changes to MA Appeals & organizational determinations
The final rule does strengthen provider appeals rights (especially in inpatient settings), but some ambiguity remains about how these rights play out across different plan contexts.
Pharmacies serving MA patients should track how their local plans handle appeals, whether providers receive appropriate notices, and whether in-network pharmacies are included in appeal communications.
Want more info on preparing patients for Medicare Open Enrollment?
Check out our how-to guide with insights and printable Medicare resources you can share with your patients to make Open Enrollment easier for them (and you!).
