CMS Issues Part D Final Rule

CMS Issues Part D Final Rule

• On April 4, 2025, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (Part D Final Rule).
• The regulations are effective June 3, 2025, with specific provisions applicable starting January 1, 2026, except as otherwise noted in the Part D Final Rule:
  • The updated cost-sharing measures for vaccines and insulin will be applicable from the beginning of the 2026 plan year.
  • The updates to marketing and communication for integrated member ID cards are applicable for all contract year (CY) 2027 marketing and communications beginning October 1, 2026.
  • The requirements related to eligibility and election, targeted outreach, and general outreach regarding participation in the Medicare Prescription Payment Plan for 2026 are applicable beginning October 1, 2025.
  • The health risk assessment (HRA) provision is applicable beginning October 1, 2026, for HRAs conducted for effective dates of enrollment on or after January 1, 2027.
  • The addition of the updated Part C Breast Cancer Screening measure is applicable for 2029 Star Ratings beginning January 1, 2027.
• CMS rejected several proposals from the Biden administration’s proposed rule, including parameters for health equity analyses, Medicare Part D and Medicaid coverage of anti-obesity medications, a review of Part D formularies and utilization management practices, and a policy on artificial intelligence.
• Among the provisions in the Part D Final Rule are requirements that:
  • Dual eligible special needs plans (D-SNPs) must provide integrated member identification cards that serve as the ID cards for both the Medicare and Medicaid plans in which the enrollee is enrolled.
  • D-SNPs are required to conduct comprehensive health risk assessments that consider both Medicare and Medicaid services.
  • The Prescription Drug Event (PDE) submission window for drugs selected under the Medicare Drug Price Negotiation Program is being shortened and plan sponsors must require their network pharmacies to be enrolled in the Medicare Transaction Facilitator Data Module.

More on This Topic:

• Final Rule
• Fact Sheet

For questions, please reach out to Vicky Jucelin.