CMS releases final rule for 2026 Medicare Advantage, prescription drug plans 

Apr 04, 2025 - 04:01 PM
CMS Final Rule

The Centers for Medicare & Medicaid Services April 4 finalized changes to the Medicare Advantage and prescription drug programs for contract year 2026. The rule finalizes proposed clarifications requiring MA and Part D plans to honor medical necessity decisions rendered as part of a prior authorization process, closes loopholes in MA appeals processes by explicitly defining organizational determinations eligible for appeal, and codifies requirements designed to improve enrollee experience interacting with dual eligible special needs plans. The administration deferred finalizing several proposals until further rulemaking can occur, including provisions on plan use of proprietary/internal coverage criteria, additional plan directory requirements and behavioral health cost-sharing. 
 
Additionally, the rule finalizes proposals regarding vaccine and insulin cost-sharing for Part D plans and requires all Part D plans to require network pharmacies to be enrolled in the Medicare Drug Price Negotiation Program’s Medicare Transaction Facilitator Data Module. 
 
The AHA is continuing to review the rule and will provide members with more information soon. 

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