Some low-income Medicare beneficiaries could eventually pay nothing for certain prescription medications under a new federal proposal that also targets inaccurate doctor directories and pharmacy benefit manager practices.
The Centers for Medicare & Medicaid Services (CMS) published a proposed rule in the Federal Register on October 20, 2026, outlining changes to Medicare Part D and Medicare Advantage.
The proposal would implement three provisions of the Consolidated Appropriations Act, 2026, which became law in February.
According to CMS, the changes are intended to reduce certain prescription costs, improve the accuracy of provider information, and strengthen oversight of pharmacy benefit managers.
Although the changes could eventually affect millions of Medicare enrollees, the proposed requirements generally target 2028 or later, meaning beneficiaries should not expect immediate changes to their 2027 coverage.
Certain Low-Income Medicare Beneficiaries Could Pay $0 for Generic Drugs
One of the most direct financial changes involves eliminating certain prescription drug copayments for qualifying low-income Medicare beneficiaries.
Under Section 6219 of the Consolidated Appropriations Act, CMS proposes reducing the generic drug copayment from $1 to $0 for full-benefit dual-eligible individuals whose income is at or below 100% of the federal poverty level.
Full-benefit dual-eligible beneficiaries are people who qualify for both Medicare and full Medicaid benefits.
The change would apply to qualifying generic drugs and certain biological products, but it would not eliminate prescription copayments for every Medicare beneficiary or every medication.
If finalized, the updated cost-sharing requirements would take effect for plan years beginning January 1, 2028.
Even Small Prescription Savings Could Help Tight Retirement Budgets
A $1 prescription copayment might not sound substantial, but recurring medication expenses can add up for retirees living on limited incomes.
For example, someone filling five qualifying prescriptions each month could save approximately $60 annually if each prescription previously carried a $1 copayment.
While that amount would not transform a household budget, it could help offset grocery expenses, transportation costs, or other everyday necessities.
CMS estimates that eliminating the qualifying copayments could improve medication affordability and reduce financial barriers to obtaining prescribed treatments.
Beneficiaries who need help paying for medications today can review eligibility for Medicare’s Extra Help program, which assists qualifying individuals with prescription drug expenses.
Medicare Advantage Doctor Directories Would Face Stricter Requirements
Another major part of the proposal addresses inaccurate provider directories maintained by Medicare Advantage insurance plans.
These directories are supposed to help beneficiaries identify doctors, specialists, hospitals, and other healthcare professionals participating in their insurance networks.
However, outdated information can create expensive problems when patients schedule appointments with providers they believe are covered, only to discover those providers are outside their plan’s network.
Under the REAL Health Providers Act, CMS proposes new verification and maintenance standards for Medicare Advantage directories beginning in contract year 2028.
The requirements would include regular verification of provider information, annual accuracy analyses, and reporting designed to make insurers more accountable for the information they provide.
Patients Could Receive Protection Against Unexpected Out-of-Network Costs
The proposed directory requirements include a potentially important financial safeguard for Medicare Advantage enrollees.
Beginning in 2028, plans would be required to provide certain cost-sharing protections when beneficiaries rely on inaccurate provider directory information and receive care from an out-of-network provider.
For example, someone who schedules an appointment based on incorrect directory information could qualify for protection against paying more than the applicable in-network cost-sharing amount.
The proposal also calls for public reporting of provider directory accuracy scores, with additional display requirements beginning in contract year 2029.
Until these protections take effect, Medicare Advantage members should continue confirming provider participation directly with their insurers and healthcare professionals before scheduling nonemergency services.
Pharmacy Benefit Managers Would Face New Accountability Rules
The third major provision focuses on pharmacy benefit managers, commonly called PBMs, which help administer prescription drug benefits for insurance plans.
PBMs negotiate drug pricing arrangements, manage formularies, and perform other services that influence how prescription medications are covered and paid for.
Under Section 6224, CMS proposes new requirements governing compensation arrangements between PBMs, their affiliates, and Medicare Part D plan sponsors.
The proposal would establish restrictions on certain compensation practices, require additional reporting, and increase transparency surrounding agreements involving drug manufacturers.
CMS also proposes compliance and enforcement mechanisms, including requirements to return certain payments received in violation of the rules.
What These PBM Changes Could Mean for Prescription Prices
Pharmacy benefit managers have faced growing scrutiny over the complexity of prescription drug pricing and the financial arrangements involved in administering drug benefits.
The proposed requirements are intended to create greater transparency about how PBMs receive compensation and how their agreements affect Medicare Part D plans.
For retirees, the potential significance lies in greater oversight of an industry that plays an important role in determining prescription coverage and costs.
However, the proposed rule does not guarantee that individual beneficiaries will see lower pharmacy prices or reduced monthly premiums.
Actual prescription expenses will continue to depend on plan coverage, drug formularies, negotiated prices, and applicable Medicare cost-sharing rules.
Public Comments Are Being Accepted Through December 15
CMS is accepting public comments on the proposed rule through December 15, 2026, at 5 p.m. Eastern Standard Time.
The proposal is identified as CMS-4214-P and appears under docket number CMS-2026-2533.
Individuals, healthcare providers, insurers, and other interested parties can review the full proposal and submit comments through Regulations.gov.
Written comments may also be mailed to CMS at P.O. Box 8013, Baltimore, MD 21244-8013, although fax submissions will not be accepted.
Because these are proposed regulations, CMS may make changes after reviewing public feedback before issuing final requirements.
What Medicare Beneficiaries Should Do While Waiting
For retirees reviewing their 2027 Medicare coverage, the most important distinction is that these proposed changes generally would not begin until 2028.
Current beneficiaries should continue comparing prescription drug coverage, provider networks, premiums, deductibles, and other costs during Medicare’s annual Open Enrollment Period.
Those concerned about prescription expenses can explore Extra Help and other assistance programs rather than waiting for the proposed copayment changes.
Medicare Advantage enrollees should also verify that their preferred doctors participate in their specific plans, especially when preparing for a new coverage year.
The proposed rules could eventually provide meaningful consumer protections, but understanding existing coverage remains essential for avoiding unexpected healthcare expenses today.
Stronger Medicare Protections Could Make a Financial Difference
The CMS proposal addresses three issues that can directly affect retirees’ finances: prescription copayments, inaccurate provider directories, and the business practices of pharmacy benefit managers.
For qualifying low-income beneficiaries, eliminating certain generic drug copayments could provide modest but recurring savings.
Stronger directory accuracy requirements could also help protect Medicare Advantage members from unexpected out-of-network expenses caused by incorrect information.
Meanwhile, increased PBM oversight could provide greater transparency into the financial arrangements behind prescription drug coverage.
What concerns you most about Medicare costs: prescription copayments, unexpected medical bills, or the way drug prices are determined? Share your thoughts in the comments.
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