This is the time of year where there aren’t many current changes to Medicare because the 2025 changes have settled, the newest income & resource guidelines for Medicare assistance programs were updated a few months ago, and any upcoming changes for 2026 are still being released. For this edition of “What’s New in Medicare,” we will instead review some of the changes from the past couple of years and share what we have on our radar for 2026.
What’s new in Medicare 2025
- Out-of-pocket threshold for prescriptions
Starting January 1, 2025, Medicare beneficiaries enrolled in a Medicare drug plan have a $2,000 limit on out-of-pocket drug costs, as long as all their prescriptions are on the drug plan’s formulary (list of covered drugs). This applies to those enrolled in a standalone Part D plan (PDP) or a Medicare Advantage plan with prescription coverage (MA-PD). However, the $2,000 cap does not include any drug plan premium, which means yearly costs in 2025 should be no more than $2,000 plus your monthly drug plan premium. - Medicare Prescription Payment Plan
In 2025, Medicare also implemented a new, optional program called the Medicare Prescription Payment Plan to help balance out prescription costs. This is especially helpful for anyone who has high drug costs the first few months; instead of spending hundreds of dollars per month before hitting the $2,000 cap, drug costs are spread out throughout the year. This program does not change the total amount of money someone will pay for drug costs – but it does balance out the full amount into more manageable payments each month. Anyone who chooses to be a part of the prescription payment plan will make payments to the drug plan, instead of at the pharmacy when filling prescriptions. For more details or to opt into the prescription payment plan, contact your drug plan or ask about the program at your pharmacy.
Upcoming for 2026
Current details about Medicare in 2026 show that there will continue to be a cap on out-of-pocket drug costs (similar to this year), but a significant change is that 2026 is the start of drug price negotiations. Starting next year, anyone enrolled in a Medicare drug plan (whether it is through a standalone drug plan or a Medicare Advantage plan) will have reduced costs on Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and NovoLog/Fiasp.
Other continued benefits
In 2026, Medicare recipients will continue to save on insulin and vaccinations. Insulin should cost no more than $35/month as long as it is an insulin covered by the drug plan (not all drug plans cover all insulins), and vaccinations should have no cost share as long as they are recommended by the Advisory Committee on Immunization Practices (ACIP). Currently, that means anyone with Medicare should have no cost share for these vaccines:
Medicare Part B Coverage
- COVID-19
- Hepatitis B (for anyone medium to high risk)
- Influenza (once per flu season)
- Pneumonia
Medicare Part D
- Shingles
- TDAP
- RSV (age 75+ or ages 60-74 with specific high-risk conditions)
For more information, check with your doctor. Anyone enrolled in a Medicare Advantage plan will also need to make sure they get the vaccine at an in-network provider (doctor or pharmacy) to have $0 cost share.
Check with your local SHIIP/SMP office during Open Enrollment (October 15th to December 7th) for any updated changes on what’s new in Medicare for 2026.