Blog

CMS 2026 Part D Redesign & the Executive Order on Drug Prices

Starting January 1, 2026, CMS will implement Medicare Part D redesign 2026 updates that were put in place by the Inflation Reduction Act. They will also enact the new Most-Favored-Nation (MFN) Executive Order issued May 12, 2025. The goal of these actions is to better align U.S. drug prices with those paid by other high-income nations.

CMS 2026 Part D Redesign: Key Cost Updates

• $615 deductible before coverage kicks in.
• Initial Coverage Phase: beneficiary pays 25% coinsurance; 65% is plan-covered, and manufacturers cover 10% (plus CMS provides a 10% subsidy on select negotiated drugs)
• Out-of-Pocket Cap: annual TrOOP limit rises to $2,100 in 2026
• Catastrophic Phase: beneficiaries pay $0; plans cover 60%, manufacturers 20%, CMS 20–40%

Watch a video on the CMS Medicare Final Rule Proposal

Selected Drug Subsidy Program & Negotiated Prices

The Direct price negotiations initiated under the IRA (Inflation Reduction Act) for the first 10 high-cost Part D drugs begins in 2026. These selected drugs also qualify for a 10% subidy, provided by CMS during the initial coverage phase.

Additionally; the expected savings for medicare is estimated at about $6 billion with an estimate of $1.5 billion in savings on beneficiary out-of-pocket costs.

Executive Order: Most-Favored-Nation Pricing (May 12, 2025)

• Directs agencies (HHS, CMS, Commerce, USTR) to benchmark U.S. drug prices against the lowest prices in OECD nations
• Encourages direct-to-consumer drug purchasing programs at these international prices
• Includes authority to impose tariffs or regulatory action if manufacturers don’t comply within 30 days
• Targets anti-competitive practices, middlemen reforms, accelerated generic and biosimilar availability, and simplified importation
• Reform measures also extend to Medicaid and facilitate value-based pricing and site-neutrality
• Implementation faces legal uncertainties, with pharmaceutical leaders raising concerns over future innovation and practicality

Medicare Prescription Payment Plan (MPPP) Updates

• Auto re-enrollment with a 3-day opt-out window for returning participants
• No extra fees and pharmacy reimbursement within 14 days (e-claims) or 30 days (paper)
• All plans must include smoothed monthly billing as an alternative to per-fill copays

What Agents Can Do

Emphasize cost cap increases: deductible ($615) and TrOOP ($2,100), and detail catastrophic phase structure.

Promote savings with negotiated drug program: mention the overall savings after the TrOOP is reached.

Educate clients about MPPP; how monthly smoothing can reduce sticker shock and how to opt out.

Highlight executive order impacts; both MFN implications and ongoing drug price negotiations that can give them additional price drops or new purchasing options.

Address drug import possibility from Canada, pending MFN implementation.

If you are ready to join the team at Crowe; click here for online contract

What This Means for Agents & Clients

• Lower costs for select medications due to CMS negotiations and MFN pricing policies
• Enhanced predictability and affordability via MPPP
• Opportunities in marketing: position these changes as saving tools during Open Enrollment
• Stay alert to implementation updates and legal progress on MFN rules

Get updated agent information and event details

Aetna SilverScript

For Medicare beneficiaries who are on Original Medicare or Original Medicare and a Medicare Supplement plan, it is a good idea to add a Medicare prescription drug plan to cover your prescriptions. One prescription drug plan that provides coverage to many beneficiaries is the Aetna SilverScript Plan.  In this post, we will go over some of the benefits these plans provide.

Aetna SilverScript Overview

Aetna SilverScript is a Medicare prescription drug plan provider.  It is part of the Aetna family of medical insurance plans. These plans are designed to work with Original Medicare or Medicare supplement plans and cannot be sold to anyone who is currently enrolled in a Medicare Advantage plan and wants to remain on that plan.

Eligibility for prescription plan enrollment

In order for a beneficiary to eligible for enrollment in any PDP plan, they must be enrolled in either Medicare Part A or both Medicare Part A & Part B.  Beneficiaries must also live in the service area of the plan they want to enroll in.

There are specific times you must use to enroll in a Medicare prescription drug plan (Part D).

1. During your initial enrollment period (IEP).
2. Enroll during the Annual Election period (AEP).
3. If you have a Medicare Advantage plan, you can enroll during the Medicare Advantage Open Enrollment Period (MAOEP).
4. When you qualify for a special election period (SEP).

Learn more about Medicare’s enrollment periods

Aetna SilverScript plans

In 2024, Aetna is offering 3 different plan choices:

1. First, the SilverScript Smart Saver plan – This plan has an average monthly premium of $11.19, Please note, this cost is an average.  Actual cost depends on the service area. This plan offers a $0 copay for a 30-day supply of Tier 1 drugs.   There are almost 600 drugs that fall into Tier 1 and Tier 2 on this plan, drugs on tier 2 have a copay amount of $5.  The SilverScript Smart Saver plan also provides members a low deductible of $280 for Tier 2 through Tier 5 drugs.
2. Second, the SilverScript Choice plan – Members of this plan pay an average monthly premium of $46.59.  Please note, this cost is an average and the actual cost depends on the service area.  There is a $545 deductible applied to all tiers of this plan.  The copay amount for Tier 1 drugs is $2 while the Tier 2 copay amount is $7.  Beneficiaries who qualify for Extra Help do not have to pay a plan premium.
3. Third, the SilverScript Plus plan – The premium for this plan averages $103.51 although the actual amount varies depending on the service area.  This is a top-notch plan that offers members a $0 deductible for both Tier 1 and Tier 2 drugs.  On this plan, there is a $0 copay for many prescription vitamins, minerals and some other types of drugs. members also receive additional gap coverage.

Watch a video on Drug plan changes for 2024

Features of Aetna SilverScript PDP plans

Variety of Plans

Aetna offers a wide range of prescription drug coverage options.  This allows beneficiaries to choose a plan that aligns with their personal needs and budget.  Each plan covers different medications at varying costs.

Extensive Network of Pharmacies

All Aetna SilverScript plans offer an extensive network of pharmacies.  This gives beneficiaries the flexibility and convenience to choose where they fill their prescriptions.

Mail-Order Options

The Aetna SilverScript plans provide the option for mail-order prescriptions, allowing beneficiaries to receive a 90-day supply of their medications conveniently delivered to their door.

Members of Aetna SilverScript PDP plans can visit AetnaMedicare.com to access and print plan materials, pay their plan premiums, check coverage of their drugs or locate a local, preferred pharmacy.

Aetna also provides members a secure site, Caremark.com, to find prescription prices, see possible prescription savings options, sign up for mail delivery, check order status and more.

Click here to learn why you should use a Medicare agent

To see if these plans are right for you, check with a licensed Medicare agent who can ensure your coverage needs are properly met by either these plans or another one.

If you would like to view more images by this artist, click here

Medicare prescription payment plan

The Medicare prescription payment plan is also referred to as “smoothing“. This is a way to help Medicare beneficiaries pay for the high cost of prescription medications.  The Medicare prescription payment plan is one small part of the inflation reduction act of 2022.

Watch a quick YouTube video on potential changes to commissions in 2025

When will the program start

In 2025, Medicare Part D (PDP) plan enrollees have a chance to opt for a prescription payment program.  The plan will help beneficiaries pay out-of-pocket costs for prescriptions.  Everyone in a PDP plan has a chance to enroll in the payment program, it is not based on income.  Enrollees have the option to enroll before the plan year starts or during any month of the year.   Please note, the payment plan does not include plan premium payments.

Here are some of the details

Participation in the Medicare prescription payment plan is optional.  PDP plan enrollees must choose to be part of the program.  Once an enrollee joins the program, and has out-of-pocket prescription costs, they receive a monthly bill to cover those costs.  Any out-of-pocket costs for prescriptions are included even during the deductible phase of PDP coverage.  There is no minimum out-of-pocket amount required before anyone can join.  Participants receive a monthly bill as long as they remain part of the program.

How is the monthly payment amount decided

There will be an annual cap of $2,000 on out-of-pocket costs in 2025.  The amount each beneficiary pays for their monthly plan depends on a few different factors.  It is not as easy as dividing $2,000 over the course of 12 months.

Learn more about the Part D drug cap

1. The Medicare prescription payment plan will deduct the out-of-pocket amount beneficiaries have already paid before enrollment in the program.
2. Any remaining costs are then divided by the number of months left in the year.

CMS will create a payment calculator so Part D beneficiaries can decide if enrolling in the payment plan is a good idea or not.

CMS is still working out the details of this program

We do not know exactly how the prescription payment program will work yet because the details have not been finalized by CMS yet.  We will post additional details as they are available to the public.

Please note:  This program is set to start in 2025, the same year the annual drug cap will be set at $2,000.  In other words, no Part D enrollee will pay more than $2,000 out-of-pocket for their prescriptions.

To view more images by this artist, click here

Medicare Prescription Drug Plans

Sign up for Medicare Part D

Once you enroll in Medicare, it is very important to Sign up for Medicare Part D.  A skilled Medicare agent can make choosing the best Medicare Part D (prescription drug plan) reasonably quick and easy.  Anyone who does not have credible Part D coverage when they are eligible for Medicare is subject to a lifelong penalty.

What does Medicare Part D cover:

Medicare Part D plans are prescription drug coverage.  This coverage is available to eligible Medicare beneficiaries. Part D coverage is provided by private insurance companies that are contracted with the federal government. There are 2 ways to enroll in Part D coverage.  First, beneficiaries may enroll in a PDP, stand-alone prescription drug plan, in addition to traditional Medicare.  The second choice is to enroll in a Medicare Advantage plan, MAPD these plans include Part D coverage.

Who is eligible for Medicare Part D:

If you are enrolled in either Medicare Part A or Part B and live in the Part D plan’s service area, you are eligible to enroll in a plan.  Additionally, certain individuals with limited income and resources are eligible for “extra help”.  Extra help provides help paying for drug plan premiums, deductibles, coinsurance and other costs.  Click here to learn more about “Extra Help” and how to apply.

When can you enroll in Part D:

To avoid late enrollment penalties, timely Medicare Part D enrollment is imperative. There are two primary enrollment periods.

The IEP or Initial Enrollment Period is a 7-month period.  It starts three months before you turn 65, includes your birth month, and ends three months after your birthday. Please note; if you qualify for Medicare due to a disability, you may have different enrollment periods.

AEP or Annual Enrollment Period occurs each year from October 15th to December 7th. During the AEP, you can make changes to your existing Part D coverage, such as switching plans or adding coverage.

How to choose a Medicare Part D Plan:

This is an extremely important part of your Part D enrollment.  If you choose the wrong plan, it can be a very costly mistake.  Each plan offers different coverage options. Selecting the right Part D plan is crucial, as each plan may have different premiums, coverage options, and their own network of pharmacies. Please consider the following when making a plan choice:

Make a list of all the medications you are currently on.  You may want to add in anything that your doctor will prescribe in the following months. Be sure to include the dosage and the frequency  that you take them.  This helps to find plans that cover your medications.

An insurance agent can show you a comparison of the best plan options for your needs.  If you  do not have an agent, use the Medicare Plan Finder tool on the official Medicare website. Be aware of all costs including; premiums, deductibles, copayments, and coinsurance costs.  You need to consider the total cost of each plan option.

Look at the plan’s formulary.  This is a list of drugs covered by each plan. Double check that your medications are on the list and make a note of any restrictions on your prescriptions.

Be sure the pharmacy you use is a preferred in-network. If it is not see if there are alternative pharmacies close by that are preferred in-network so you can receive the best pricing.

Check the plan’s star ratings.  This is  system based on overall service and coverage.

How to enroll in Part D:

Once you choose the best Medicare Part D plan to meet your prescription coverage needs, you have a few ways to enroll.

1.  Online: A licensed Medicare agent may be able to enroll you using an enrollment link from their quoting engine or you can enroll by going to either Medicare.gov or the website of the carrier of the plan you selected.

Click here to view a demo of how to use Sunfire to run a quote

2.  Fill out a paper application.  If you are working with an agent, they will help you fill out the necessary paperwork and send the application in for you.  If you do not have an agent, you can submit the application using the instructions provided by the carrier.

3.  Enroll over the phone.  You can call the plan carrier or call 1-800-633-4227 (1-800-Medicare).

Beware of late enrollment penalties:

If you miss your Initial Enrollment Period or do not have creditable prescription drug coverage for over 63 days, you may wind up with a late enrollment penalty. This penalty is added to your Part D premium and remains in effect for as long as you have Part D coverage.  Please note; if you receive extra help, this penalty does not apply.

If you are an agent and wish to contract with Crowe and Associates; click here.

To view more images by this artist; click here