Significant upcoming Medicare changes include key updates and new rules for 2026, primarily affecting drug costs, telehealth services, and costs for Original Medicare and Medicare Advantage
Upcoming changes for 2026
Expect a significant increase, potentially to $206.50 per month, a roughly 11.6% rise from 2025’s $185.00 premium.
New CMS Initiative
The Centers for Medicare & Medicaid Services (CMS) has introduced the Wasteful and Inappropriate Service Reduction (WISeR) Model to fight fraud, waste, and abuse in Original Medicare.
- Focus on Technology:
This model will partner with technology companies to improve and expedite the prior authorization process for certain services.
Further prescription drug cost updates
- $2,100 out-of-pocket cap: The annual out-of-pocket cap on Part D prescription drugs will increase slightly to $2,100.
- Negotiated drug prices: The first set of drugs subject to Medicare’s price negotiation program under the Inflation Reduction Act will see new, lower costs take effect.
- Insulin cap expansion: The $35 cap on monthly insulin costs will become more flexible, with enrollees potentially paying even less, depending on negotiated drug prices.
Expanded prior authorization
- Prior approval for some Original Medicare services: For the first time, a pilot program in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington) will require prior authorization for certain procedures under Original Medicare. Affected services include some back, knee, and nerve procedures.
Medicare Advantage changes
- Fewer non-health supplemental benefits: Medicare Advantage (MA) plans will face new restrictions on the non-health items they can offer under special supplemental benefits, with prohibitions on items such as alcohol and tobacco.
- Insurer adjustments: Some insurers are exiting or scaling back their Medicare Advantage offerings in certain markets. Beneficiaries should review their options during the open enrollment period, from October 15 to December 7, 2025.
Potential program cuts
- Deficit concerns: According to the Congressional Budget Office, potential legislation could lead to automatic, deep cuts to Medicare funding beginning in 2026.
What drugs will have negotiated prices in 2026?
Under the Medicare Drug Price Negotiation Program, the Centers for Medicare & Medicaid Services (CMS) has selected
10 drugs for price negotiation that will take effect on January 1, 2026. These negotiations represent a significant step in lowering prescription drug costs for Medicare beneficiaries.
The drugs selected for negotiation for the 2026 price year are:
- Eliquis (Apixaban), a blood thinner
- Jardiance (Empagliflozin), for diabetes, heart failure, and chronic kidney disease
- Xarelto (Rivaroxaban), a blood thinner
- Januvia (Sitagliptin), for diabetes
- Farxiga (Dapagliflozin), for diabetes, heart failure, and chronic kidney disease
- Entresto (Sacubitril/Valsartan), for heart failure
- Enbrel (Etanercept), for rheumatoid arthritis, psoriasis, and psoriatic arthritis
- Imbruvica (Ibrutinib), for blood cancers
- Stelara (Ustekinumab), for psoriasis and Crohn’s disease
- NovoLog/Fiasp (Insulin Aspart), for diabetes
Negotiation Details
- Negotiated prices for these drugs range from 38% to 79% discounts off their 2023 list prices.
- CMS estimates these negotiated prices would have saved Medicare $6 billion in 2023 and are projected to save beneficiaries $1.5 billion in out-of-pocket costs in 2026.
- The negotiation process considered factors such as research and development costs, market/revenue data, and clinical benefits compared to alternative treatments.