With a new administration in Washington and a new administrator named to head CMS, there have been questions about the Medicare benefits enacted by the previous administration’s Inflation Reduction Act of 2022. Will these provisions stay in place for 2026, or will they be reversed? Let’s take a look at which benefits will be changing and which will remain the same for the upcoming year.
Which Benefits Are Changing?
Part D Cap on Out-of-Pocket Expenses Increases
The Part D cap will be adjusted for inflation to $2,100 in 2026, a slight increase from $2,000 in 2025.
All Recommended Vaccines Will Be Covered in Full
In 2026, all CDC-recommended vaccines will be fully covered, with no cost share. It’s important to note that the list of recommended vaccines is updated annually, meaning what is covered one year may not be covered the next.
Medicare Will Not Cover GLP-1 Weight Loss Drugs
While the previous administration had proposed moving forward with coverage for GLP-1 weight loss medications, the current administration has made the decision that Medicare will not be covering these medications in 2026 when they are prescribed for weight loss. Medicare does offer coverage for these medications when they are prescribed to treat diabetes.
Which Benefits Remain the Same?
Insulin Costs Remain Capped at $35 or Less
Insulin costs will remain capped at $35 or less per month and will not be subject to a deductible. In 2026, the monthly insulin copay will be the lowest of the following:
- $35
- 25% of the drug’s negotiated price
- 25% of the new Medicare Fair Price
This means that if Medicare can negotiate lower prices for insulin, the medications could cost less than $35.
The Medicare Prescription Payment Plan Continues
The Medicare Prescription Payment Plan (MPPP), which helps spread out prescription costs over the year, will remain in place for 2026. Anyone who participated in the MPPP in 2025 will automatically be re-enrolled in the plan for 2026. Insurers must send a separate renewal notice to participants at the end of AEP disclosing the MPPP’s terms and conditions. Current participants who do not want to be part of the program in 2026 must take action to opt out.
Medicare Drug Price Negotiations Will Continue
CMS plans to continue negotiations with drug manufacturers to lower the prices of expensive brand-name medications used to treat chronic conditions. Lower prices from the first round of negotiations go into effect in 2026. The next round of negotiations is expected to result in lower prices, which will take effect in 2027.
What Is Unknown at This Time?
One provision of the Inflation Reduction Act is the Part D Premium Stabilization Act, which protects enrollees in stand-alone Part D plans from unexpected Part D premium spikes. It limits increases in the base beneficiary premium to no more than 6% above the previous year’s premium. It is unknown whether the Trump administration will continue this provision for a second year. It is anticipated that a termination would result in a reduction of the number of PDP plans available, especially in rural areas, which could prompt a further shift from Original Medicare to Medicare Advantage plans. An announcement is expected by the end of summer.
Prepare Your Clients for the Upcoming Changes
Many of the changes to Part D benefits will be reflected in insurers’ drug formularies for 2026. It’s not too early to start thinking about your communication with your clients in preparation for AEP. Please ensure that your PDP and MA clients are notified that they will receive their ANOC in the mail in September. They should carefully review these notifications for any changes that may impact them next year. Remind your clients that AEP is right around the corner and you are here to help answer any questions they have. Encourage them to call you to set up an appointment after October 1, when you can begin discussing 2026 coverage options.
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