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Medicare Advantage Unused Benefit Rules – What Agents Need to Know

Medicare Advantage (MA) plans can be a great choice for clients; especially because of their extra perks like dental, vision, hearing, OTC allowances, and fitness memberships. But these benefits often go unused, which can lead to client dissatisfaction and plan switching. Recently, CMS has put some Medicare Advantage unused benefit rules in place.

Here’s what you need to know to guide your clients.

Key Points About Unused Benefits

• Most benefits expire monthly, quarterly, or annually; no rollovers.
• OTC allowances are among the most commonly missed benefits.
• Dental/vision/hearing dollars disappear at year-end if not used.
• Provider networks matter — clients must follow plan rules or they risk missing out on some benefits.

CMS’ Mid-Year Notification Rule

CMS recently finalized a rule requiring MA plans to send personalized mid-year notices (June 30–July 31) showing members which supplemental benefits they haven’t used and how to access them.

However, enforcement is paused for 2026, so most plans will not send these reminders. Some may do so voluntarily, but agents should not assume clients will get them.

Watch a YouTube video: Why agents should include ancillary products with MA sales

Why This Matters for Agents

• Client Retention: Clients often switch plans because they feel they aren’t getting value; even when benefits were available.
• Education Opportunity: Helping clients understand and use their benefits builds trust and keeps them engaged.
• Competitive Edge: Agents who proactively remind clients about OTC orders, dental visits, and other benefits stand out.

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Agents

• Review each client’s benefits during mid-year check-ins.
• Send reminders about quarterly OTC allowances and annual dental/vision appointments.
• Explain provider network requirements to avoid frustration.
• Track CMS updates; when they enforce the rule, you can align your outreach with plan notices.

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Even with CMS’ rule delayed, agents can fill the gap by educating clients and helping them use the benefits they signed up for. Proactive communication strengthens client relationships, improves satisfaction, and keeps your book of business stable.

Medicare Coverage of DME (Durable Medical Equipment)

When it comes to staying healthy and independent, many Medicare beneficiaries rely on durable medical equipment (DME). Whether it’s a walker, a hospital bed, or a CPAP machine, understanding Medicare coverage of DME is essential for many.

In this post, we’ll break down what DME is, how Medicare covers it, and what clients should know to avoid costly surprises.

What Is Durable Medical Equipment (DME)

Durable Medical Equipment is defined as reusable medical equipment that is:

• Medically necessary for the patient’s health condition
• Able to withstand repeated use
• Primarily used for a medical purpose
• Appropriate for use in the home

Examples of common DME include:

• Wheelchairs and scooters
• Walkers and canes
• Hospital beds
• Oxygen equipment
• Blood sugar monitors and test strips
• CPAP machines and supplies

How Medicare Covers DME

Medicare Part B

Most DME is covered under Medicare Part B (Medical Insurance). Here’s how it works:

• Doctor’s Order Required: A physician or other Medicare-approved provider must prescribe the equipment.
• Approved Supplier: The equipment must be purchased or rented from a Medicare-approved supplier that accepts assignment.
• Cost-Sharing: The beneficiary pays 20% of the Medicare-approved amount after meeting the Part B deductible.

Those who have a Medicare Supplement plan may pay as little as $0 depending on the plan they have.

Some equipment is available for purchase, while other items are only available for rental. For rentals, Medicare usually pays the supplier monthly for up to 13 months, after which the beneficiary typically owns the equipment.

Watch a YouTube Video on Advanced Diabetes Supply – Help clients get the supplies they need.

Prior Authorization and Competitive Bidding

In some cases, Medicare requires prior authorization for certain high-cost or frequently abused items (like power wheelchairs). Additionally, in certain areas, Medicare runs a competitive bidding program for DME, meaning beneficiaries must use specific contracted suppliers to get full coverage.

Medicare Advantage and DME

Medicare Advantage (Part C) plans also cover DME, but:

• Networks and suppliers may be different from Original Medicare.
• Some plans require prior authorization for more types of equipment.
• Cost-sharing may vary (some plans may have lower copays or coinsurance).

Agents should always remind clients to check their plan’s provider directory and approval process before ordering DME.

Tips for Agents and Beneficiaries

• Verify Coverage First: Always confirm that the prescribing provider and supplier are Medicare-approved.
• Check the Need: Make sure there’s documentation showing the equipment is medically necessary.
• Understand Costs: Explain that clients will still owe 20% coinsurance under Part B unless they have Medigap or other supplemental coverage.
• Watch for Scams: DME fraud is common – warn clients not to accept unsolicited equipment or offers.

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Durable Medical Equipment can be life-changing for Medicare beneficiaries, but coverage rules can be tricky. By helping your clients understand what Medicare covers, where to get equipment, and how to keep costs low, you can build trust and ensure they get the care they need without unexpected bills.

2026 Medicare Part D Costs & Drug Price Negotiations

Medicare Part D (the prescription drug benefit) has seen some major changes recently. For 2026, several provisions are coming into play that affect what enrollees pay, how much Medicare pays, and how drug prices are negotiated. Below are the key updates to the 2026 Medicare Part D costs.

Key Changes in Medicare Part D for 2026

Here are some of the most important cost‐related changes that beneficiaries should know:

What Is the Drug Price Negotiation Program

Under the Inflation Reduction Act of 2022, Medicare now has the power to directly negotiate prices for certain high-cost drugs covered under Part D (and later also Part B). Previously, Medicare was more restricted in its ability to force manufacturers to lower prices for prescription drugs.

Here’s how the negotiation program works in broad strokes:

• Each year, a certain number of “single-source” brand drugs (i.e. those without generics or biosimilars) that have been on the market for a set minimum time become eligible for negotiation.
• Medicare (through CMS) makes an initial offer (“maximum fair price” or MFP) based on drug spending, clinical benefit, manufacturer costs, price in comparable drugs, etc. Manufacturers can counter. There are meetings and data sharing to arrive at a negotiated price.
• If agreement is reached, the negotiated price becomes effective as of a certain date. For the first set of drugs, prices begin for 2026

Watch a quick YouTube video on the Medicare Prescription Payment Plan

Which Drugs & Savings with Negotiation in 2026

• The first round of negotiation selects 10 Part D drugs.
• For 2026, these negotiated prices go into effect starting January 1, 2026.
• The discounts negotiated are substantial: for those 10 drugs, reductions range from 38% to 79% off list price.
• Estimated savings: If those new prices had been in effect earlier (e.g. in 2023), Medicare would have saved about $6 billion in overall drug spending on those drugs. For beneficiaries, out-of-pocket savings for those 10 drugs in 2026 are projected to be about $1.5 billion.

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How Negotiations & Costs Interact: What This Means for Beneficiaries

• Lower list/transaction prices for selected drugs should directly reduce what beneficiaries pay (especially in the initial and gap phases), because coinsurance or cost sharing is often a percentage of drug cost.
• The out-of-pocket cap ($2,100 in 2026) limits how high total costs for drugs can go in a year, making unexpected high drug bills somewhat more predictable.
• The negotiation program may also influence which drugs are placed on formularies or on preferred tiers, as plans respond to the new negotiated prices.
• However, the savings from negotiated drugs apply only to those drugs selected for negotiation; many other drugs will still be under traditional pricing structures.

Some Caveats & Things to Watch

• The negotiated max fair price is not always simply a percentage cut—there are statutory minimum discounts, comparisons with existing net prices, evaluation of alternatives, etc. Some drugs may see smaller reductions depending on existing rebates or other discounts.
• The program phases in over years: more drugs will be subject to negotiation in 2027, 2028, etc. So the full effects take time.
• Courts and industry challenges may affect implementation or enforcement.

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For 2026, people with Medicare should expect higher costs including; premiums, deductibles and out‐of‐pocket thresholds compared to previous years. Although there will be relief for certain high‐cost drugs thanks to the new Medicare drug price negotiation program. If you’re taking one of the drugs selected for negotiation, the discounts will reduce what you pay. Over time, broader negotiation and other reforms aim to make more drugs more affordable for all Part D enrollees.

Medicare Costs for 2026 – What Beneficiaries Need to Know

Each year, Medicare updates the premiums, deductibles, and coinsurance amounts for Parts A and B. These changes can have a significant effect on your budget; especially if you are living on a fixed income. Below we go over the projected Medicare costs for 2026. We have included a brief look at Part D and the high-deductible Medigap option.

Medicare Part A Costs for 2026

Medicare Part A covers inpatient hospital care, skilled nursing facility care, hospice, and some home health services. Most people do not pay a Part A premium, but you are still responsible for deductibles and coinsurance amounts.

• Part A deductible (per benefit period): Projected to rise from $1,676 in 2025 to about $1,716 in 2026.
• Hospital coinsurance (days 61–90): Expected to increase from $419/day to around $429/day.
• Lifetime reserve days (beyond day 90): Rising from $838/day to about $858/day.
• Skilled Nursing Facility coinsurance (days 21–100): Expected to increase to about $214.50/day.

Since the Part A deductible applies per benefit period, you could pay it more than once in a year if you have multiple hospital stays separated by 60+ days.

Medicare Part B Costs for 2026

Part B covers outpatient services, doctor visits, preventive care, and durable medical equipment.

• Standard Part B premium: Expected to increase from $185/month in 2025 to around $206.50/month in 2026.
• Part B annual deductible: Projected to rise from $257 to about $288 in 2026.

After you meet your Part B deductible, Medicare generally covers 80% of approved charges, leaving you responsible for the remaining 20% unless you have supplemental coverage.

Part D Prescription Drug Costs (Quick Note)

Even though Part D is separate from Parts A & B, it’s worth noting that the maximum Part D deductible is expected to increase from $590 in 2025 to $615 in 2026. There will also be a new out-of-pocket cap of $2,100 for covered drugs (it was $2,00 in 2025), which helps those with high prescription costs.

High-Deductible Medigap (HDG) Plans – A Quick Overview

For those who purchase a high-deductible Medigap plan (Plan G or F), the annual deductible must be met before the plan starts paying for costs that Original Medicare doesn’t cover.

• The 2025 high-deductible amount is $2,870.
• The 2026 amount has not yet been finalized but is expected to rise slightly in line with medical inflation.

These plans often have lower monthly premiums, making them attractive for healthier beneficiaries who expect lower healthcare usage, but you’ll need to budget for that large deductible in case of an unexpected illness or hospitalization.

Watch a YouTube video on High Deductible G Plans

Why This Matters

The projected increases in Part B premiums and deductibles could take a big bite out of Social Security cost-of-living adjustments. Planning ahead helps you avoid surprises.

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Here’s what clients should do:

• Budget for higher premiums and deductibles.
• Review supplemental coverage to ensure it still meets your needs and budget.
• Compare Part D plans during the Annual Enrollment Period (AEP) to find one that best covers medications at the lowest cost.
• Stay informed—CMS will finalize these numbers in Fall 2025, so check back for updates.

Understanding Medicare Deductibles

Medicare deductibles are one of the most important; and sometimes confusing, parts of how Medicare works. Whether your clients are on Original Medicare or a Medicare Advantage plan, understanding Medicare deductibles is an important part of healthcare decisions. Knowing what they are, when they apply, and what services count toward them can help avoid costly surprises.

As an agent, being able to break this down simply is a great way to build trust and guide clients to the right coverage.

What Is a Medicare Deductible

A deductible is the amount a beneficiary must pay out of pocket for covered services before Medicare or their Medicare plan starts sharing the cost.

There are several types of Medicare deductibles:

• Medicare Part A Deductible – applies to each benefit period for inpatient hospital care.
• Medicare Part B Deductible – applies once per calendar year for medical services like doctor visits and outpatient care.
• Medicare Advantage (Part C) Deductible – set by the private plan and may apply to medical, drug coverage, or both.
• Medicare Part D Drug Deductible – applies to certain prescription drugs (usually higher-tier medications).

Watch a quick YouTube video on Medicare Advantage vs. Medicare Supplements

Services That Use Deductibles

Here’s what typically applies to each deductible:

• Part A (Hospital) Deductible:
  • Inpatient hospital stays
  • Skilled nursing facility care (after meeting Part A requirements)
  • Some home health care and hospice services
• Part B (Medical) Deductible:
  • Physician visits
  • Outpatient surgery
  • Diagnostic tests (labs, X-rays, imaging)
  • Durable Medical Equipment (DME)
  • Preventive care is usually exempt — covered at 100%
• Medicare Advantage Deductible:
  • Inpatient hospital care (if plan requires it)
  • Outpatient hospital/surgical care
  • Advanced diagnostic imaging (MRI, CT scans)
  • Durable Medical Equipment (DME)
  • Emergency/urgent care (sometimes)
• Part D Deductible:
  • Applies to most Tier 3 and higher brand-name drugs
  • Generic drugs on lower tiers may bypass the deductible

Services That Skip the Deductible

To keep care accessible, Medicare and Medicare Advantage plans often waive the deductible for:

• Preventive screenings (wellness visit, mammogram, colonoscopy)
• Routine lab work
• Many primary care visits
• Many Tier 1 and Tier 2 generic prescriptions

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Deductibles Are Just One Piece of the Puzzle

When reviewing coverage options with clients, don’t just look at the deductible amount. Also compare:

• Coinsurance and copays – what clients pay after meeting the deductible
• Maximum Out-of-Pocket (MOOP) on Medicare Advantage plans
• Medigap coverage – many Medigap plans cover some or all deductibles, reducing out-of-pocket costs

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By helping clients understand when and how deductibles apply, you make it easier for them to budget for healthcare and choose the plan that fits their needs.

The Medigap Free Look Period and How to Use It

When clients are considering a Medicare Supplement (Medigap) plan, they want to be sure they’re making the right choice. Fortunately, Medicare gives beneficiaries a way to try out a new Medigap plan without fully giving up their old one; it’s called the Medigap Free Look Period.

As an agent, knowing how this works helps you guide clients through transitions confidently and avoid gaps in coverage.

What Is the Medigap Free Look Period

The Medigap Free Look Period is a 30-day window that allows Medicare beneficiaries to try out a new Medigap policy while keeping their current one.

This is helpful when a client isn’t sure if the new plan will meet their needs; for example, if they are switching from a Plan F to a Plan G or moving to a carrier with a lower premium.

Watch a YouTube video on Medicare Supplement Underwriting (GI & Non-GI States)

How the Free Look Period Works

Here’s how the process goes step by step:

1. Apply for the New Medigap Plan
   • Your client must be accepted by the new Medigap plan (and if underwriting is required, they must pass).
2. Keep Paying for the Old Policy
   • Even after the new plan starts, your client must keep paying premiums for their old Medigap policy during the 30-day free look period.
   • This ensures there’s no gap in coverage if they decide to go back.
3. Evaluate the New Coverage
   • Over the 30 days, your client can use the new Medigap plan and see how it works with their needs.
4. Decide Whether to Keep It
   • If they like the new plan, they can cancel the old one after the 30 days.
   • If they don’t, they can cancel the new plan and keep the old one; no harm done.

Important Things to Remember

• Two Premiums Are Due: Clients will pay two Medigap premiums during the free look period; one for the old plan and one for the new. This is often the biggest surprise for beneficiaries, so prepare them ahead of time.
• Coverage Overlap Is Intentional: The goal is to avoid any lapse in coverage while deciding which plan to keep.
• Act Within 30 Days: If the client decides to go back to their old policy, they must notify the new carrier before the free look period ends.

Why Agents Should Talk About It

Educating clients about the Medigap Free Look Period builds trust. Many people hesitate to switch plans out of fear of losing coverage or making the wrong choice. When you explain that they can try a new plan risk-free, you help them feel confident in making a change. That helps position you as a knowledgeable, client-first agent.

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The Medigap Free Look Period is a great tool to help beneficiaries compare coverage and costs without the stress of losing their existing plan. As an agent, you can guide them through the process, set clear expectations about paying two premiums, and help them decide which plan is the best long-term fit.

Empower your clients with this knowledge; it may be exactly what they need to take the next step toward better coverage and savings.

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What Is a Medicare Authorized Representative

Navigating Medicare can sometimes feel overwhelming; especially when it comes to forms, appeals, or plan decisions. That’s where a Medicare Authorized Representative comes in. If you need help dealing with Medicare, you can officially appoint someone to act on your behalf. But what is a Medicare authorized representative, and what are the limits to their authority? Let’s break it down.

What Is a Medicare Authorized Representative

A Medicare Authorized Representative is a person you choose to act for you in handling certain Medicare matters. You can name a trusted family member, friend, caregiver, or even a professional (like an attorney) to represent you.

To make this official, Medicare requires you to complete the “Appointment of Representative” form (CMS-1696) or provide a written statement that includes specific details. Once approved, Medicare recognizes this person as your representative for the issues you’ve specified.

What an Authorized Representative Can Do

When properly appointed, your authorized representative can:

• Communicate with Medicare on your behalf – including discussing claims, coverage, and appeals.
• File appeals or grievances – if you disagree with a coverage or payment decision.
• Submit plan enrollment or disenrollment requests – depending on your needs.
• Receive notices and correspondence from Medicare related to your case.
• Help you gather and send supporting documentation for appeals or claims.

Essentially, your representative steps into your shoes for specific Medicare-related matters, making the process less stressful for you.

What an Authorized Representative Cannot Do

It’s important to understand the limits of this role. A Medicare Authorized Representative cannot:

• Make medical decisions for you – They are not the same as a healthcare proxy or power of attorney for medical treatment.
• Automatically handle all financial or legal matters – Their authority is limited to Medicare issues.
• Act indefinitely without renewal – Representation typically applies to specific cases or timeframes and may need renewal if ongoing.
• Override your wishes – You remain in control, and you can revoke their authority at any time.

If you want someone to handle broader decisions about your finances or healthcare beyond Medicare, you would need a power of attorney or similar legal document.

Watch a YouTube video on Medicare enrollment periods

How to Appoint a Representative

1. Fill out Form CMS-1696 – This form is available on Medicare.gov or from your plan.
2. Submit the form – Send it to your Medicare Advantage, Part D, or other Medicare-related plan, or directly to Medicare if it’s about Original Medicare.
3. Wait for confirmation – Once accepted, your representative can begin acting on your behalf.

Why Appointing a Representative Can Help

Having a Medicare Authorized Representative can be especially useful if:

• You’re appealing a denial of coverage.
• You need help managing the paperwork.
• You have a trusted advocate who understands your situation.
• You want extra peace of mind that someone is handling your case correctly.

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Bottom line: A Medicare Authorized Representative is your advocate in dealing with Medicare, but their authority is limited to Medicare-related issues. They can help with forms, appeals, and communication, but they cannot make medical decisions or handle unrelated legal or financial matters.

Why Sell Life Insurance

For insurance professionals, adding life insurance to your portfolio is one of the smartest career moves you can make. Why sell life insurance; it’s not only a product in high demand, it’s also a powerful way to add income, expand and your client base. It has the ability to help build a business that provides stability for years to come.

High Demand Creates Opportunities

Life insurance isn’t a luxury; it’s a necessity. Every stage of life presents a need for coverage, from young families protecting their income, to seniors planning for final expenses, to business owners securing succession plans. This universal demand means a steady stream of prospects and opportunities for sales.

High Commissions and Residual Income

One of the biggest advantages of life insurance sales is the income potential. Many carriers pay competitive first-year commissions on policies, and renewals can create residual income year after year. By maintaining strong client relationships and policy retention, you’re rewarded with ongoing revenue without starting from scratch each year.

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Expand Your Cross-Selling Potential

Selling life insurance opens the door to other products and services. Once you’ve earned a client’s trust with life insurance, you can position yourself as their go-to advisor for Medicare plans, annuities, long-term care, or other ancillary products. Every life insurance policy can become the foundation for a long-term client relationship and additional sales.

Build a Referral Network

When you provide families with peace of mind and financial security, you naturally create satisfied clients who are willing to refer friends and loved ones. Referrals are one of the strongest ways to grow your business, and life insurance sales generate them consistently.

A Recession-Resistant Career

In uncertain economic times, financial protection becomes more important, not less. Families want security and businesses need continuity. Selling life insurance puts you in a resilient market that remains in demand regardless of the economy.

Watch a YouTube video on Life Insurance Quoting and Sales

Professional Growth and Authority

Life insurance agents often become more than salespeople; they become trusted financial advisors. By helping clients understand coverage options, needs analysis, and long-term planning, you elevate your credibility and position yourself as an expert in your community.

Make a Meaningful Impact While Building Wealth

Yes, life insurance sales can provide significant income and residuals, but it also gives you the satisfaction of knowing you’re making a difference. Few careers allow you to both grow your wealth and leave a lasting positive impact on the lives of your clients.

Selling life insurance is one of the most profitable and sustainable opportunities in the insurance industry. It offers agents strong commissions, renewals, cross-selling opportunities, and a career path that is both financially rewarding and personally fulfilling.

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If you’re looking for a way to grow your book of business and secure long-term income, life insurance is a product you can’t afford to overlook.

Medicare Supplement Underwriting Explained

When clients start exploring Medicare Supplement (Medigap) plans, one topic that often causes confusion is underwriting. Unlike Medicare Advantage plans, which don’t require medical underwriting, Medigap coverage can involve health-related questions and approval requirements; depending on when and how someone applies. That is why we hope, Medicare supplement underwriting explained will provide an understanding of the process so agents can better assist clients.

What Is Medicare Supplement Underwriting

Underwriting is the process insurance companies use to determine whether to accept an applicant for a Medigap policy, and sometimes the determine the premium amount. This process often involves answering health questions, reviewing prescription history, or even checking recent hospitalizations.

Not every applicant will face underwriting, many people qualify for guaranteed issue rights or are in their Medigap Open Enrollment Period, which means they can get a plan without medical review.

When Is Underwriting Required

Underwriting typically comes into play in these situations:

• Applying outside the Medigap Open Enrollment Period (which lasts six months after a beneficiary first enrolls in Part B at age 65).
• Switching from one Medigap plan to another outside of specific state-mandated open enrollment or “birthday rules.”
• Losing coverage without qualifying for guaranteed issue rights.

In these cases, insurance carriers can:

• Approve coverage at the standard rate,
• Charge a higher premium,
• Impose a waiting period for pre-existing conditions, or
• Deny coverage altogether.

Guaranteed Issue Rights (No Underwriting Required)

There are special circumstances where a beneficiary can enroll in a Medigap plan without facing underwriting, such as:

• Losing employer or union coverage.
• Their Medicare Advantage plan leaving the service area or ending coverage.
• Moving out of a Medicare Advantage plan’s service area.
• Taking advantage of certain state-specific enrollment protections (like California and Oregon’s Birthday Rule, or Missouri’s Anniversary Rule).

During these times, carriers must offer coverage, regardless of health status.

Watch a quick YouTube video on Medicare Supplement Underwriting

Common Health Questions in Underwriting

While exact questions vary by carrier, underwriting often includes:

• Recent heart attacks, strokes, or cancer diagnoses.
• Use of oxygen, dialysis, or organ transplants.
• Height, weight, and mobility concerns.
• Hospitalizations in the past 90 days.
• Use of certain expensive medications.

Carriers typically ask about conditions that are costly and ongoing. Clients with stable, controlled conditions may still qualify.

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Why Agents Should Understand Underwriting

As an agent, knowing the underwriting rules helps you:

• Advise clients on the best time to apply for Medigap coverage.
• Set realistic expectations about approvals, denials, or higher premiums.
• Protect clients by helping them avoid losing a plan they may not be able to requalify for later.

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Underwriting for Medicare Supplements can be straightforward if clients apply at the right time, but tricky if they wait too long or want to change plans later. By understanding the process and knowing when underwriting applies, you can help your clients secure coverage that supports their health and budget without unexpected roadblocks.

Medicare’s 2026 Drug Price Negotiations: A New Era of Affordability

Starting January 1, 2026, Medicare will implement its first-ever negotiated prescription drug prices; a historic change that could lower costs for millions of beneficiaries. In this post, we discuss Medicare’s 2026 Drug Price Negotiations. This is a direct result of the Inflation Reduction Act of 2022, which for the first time gave Medicare the authority to negotiate the prices of certain high-cost medications.

Why This Matters

For decades, Medicare was prohibited from negotiating directly with drug manufacturers. Instead, it relied on private Part D plan sponsors to manage drug costs. The 2026 negotiations mark a turning point. Medicare will now establish a Maximum Fair Price (MFP) for select drugs, reducing both what the government pays and what beneficiaries spend at the pharmacy counter.

• Projected Medicare savings: About $6 billion in 2026
• Projected out-of-pocket savings for beneficiaries: About $1.5 billion

The First 10 Drugs Negotiated for 2026

CMS chose these drugs because; they are some of the highest-cost Part D medications. In addition; there are no generic or biosimilar medications available, and are widely prescribed.

1. Eliquis – blood thinner for preventing stroke and blood clots
2. Xarelto – blood thinner for reducing risk of clotting
3. Januvia – diabetes medication (DPP-4 inhibitor)
4. Jardiance – diabetes, heart failure treatment (SGLT2 inhibitor)
5. Farxiga – diabetes, heart failure, kidney disease treatment (SGLT2 inhibitor)
6. Entresto – heart failure medication
7. Enbrel – rheumatoid arthritis and autoimmune conditions
8. Stelara – psoriasis, Crohn’s disease, ulcerative colitis
9. Imbruvica – blood cancers (leukemias and lymphomas)
10. NovoLog / Fiasp – fast-acting insulin for diabetes

How Beneficiaries Will Benefit

• Lower copays and coinsurance: Out-of-pocket costs will drop for patients taking these medications.
• Broader affordability: Even if you don’t take one of these drugs, Medicare’s overall savings help stabilize Part D premiums.
• Expanded impact in future years: In 2027 and beyond, CMS has scheduled more drugs for negotiation.

Watch a YouTube video on the Inflation Reduction Act and Changes to Medicare

What Comes Next

• 2027: Fifteen more high-spend drugs are already set to be negotiated, with prices effective January 1, 2027.
• 2028 and beyond: CMS will continue expanding the program, selecting additional drugs each year.
• Rulemaking: Starting in 2026, the program shifts to a formal rulemaking process, adding more transparency.

Challenges and Legal Pushback

The pharmaceutical industry has filed multiple lawsuits challenging Medicare’s new authority, arguing that price negotiations are unconstitutional. At the same time, new legislation has delayed or exempted certain blockbuster drugs, such as Keytruda, from early negotiation. While these challenges could affect the program’s scope, the 2026 savings are locked in and moving forward.

What You Should Do

• Review your Medicare Part D plan during open enrollment to ensure it covers your prescriptions at the lowest cost.
• Talk to your agent if you take any of the drugs on the 2026 negotiation list, you could see meaningful savings.
• Stay informed about future negotiation cycles, as more medications are added each year.

Agents:

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Medicare’s 2026 drug price negotiations represent a historic shift in prescription drug policy. For the first time, Medicare is actively reducing the cost of some of the most expensive and widely used medications in the program. While legal and political challenges remain, the immediate savings for beneficiaries and taxpayers are significant—and this is only the beginning.