From new prescription drug limits to tighter rules on Medicare Advantage perks, the Medicare changes for 2026 are more than small adjustments — they could directly impact how much you pay and what benefits you receive. If you’re not watching closely, you could end up with higher out-of-pocket costs or lose extras you’ve counted on.
Skyline Benefit is an independent Medicare insurance broker helping seniors nationwide navigate these updates with clarity and confidence. Here’s a breakdown of what’s changing in 2026 — and how to prepare.
What’s Happening to Medicare Prescription Out-of-Pocket Caps?
Among the most impactful Medicare changes for 2026 are the adjustments to Part D out-of-pocket limits, which could shift your annual prescription costs. Medicare Part D’s annual spending cap — introduced under the Inflation Reduction Act — will increase from $2,000 in 2025 to $2,100 in 2026. Once you reach that cap, all covered prescriptions cost $0 for the rest of the year.
Will the Medicare Prescription Payment Plan Automatically Renew?
Yes — starting in 2026, if you’re enrolled in the Medicare Prescription Payment Plan (MPPP), your participation will automatically roll over into the next year.
The MPPP spreads your prescription drug costs evenly over 12 months, rather than requiring large upfront payments. If you want to opt out, your plan must now process the request within three calendar days, making it faster and easier to leave the program.
Which Extra Perks Are Disappearing from Medicare Advantage?
Medicare Advantage carriers will face stricter rules on SSBCI (Special Supplemental Benefits for the Chronically Ill). Beginning in 2026, plans can no longer offer certain non-medical perks, including:
- Alcohol, tobacco, or cannabis
- Funeral or life insurance benefits
- Cosmetic procedures not covered by Original Medicare
- Discount programs unrelated to healthcare
- Junk food or unhealthy groceries
- Hospital indemnity or other unrelated insurance products
If you picked a Medicare Advantage plan because of these extras, it’s worth reviewing your 2026 plan details to see what’s staying.
Is Insulin Still Capped at $35 in 2026?
Yes — but with a new twist. Starting in 2026, you’ll pay the lowest of:
- $35
- 25% of the negotiated price, or
- 25% of the maximum fair price
This applies to both standalone Part D and Medicare Advantage plans with prescription coverage — and there’s still no deductible for covered insulin.
Will Medicare Still Cover Free Adult Vaccines?
Yes. Medicare Part D must continue covering $0-cost vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP). This includes shingles, pneumonia, flu shots, and others based on age or health status.
Since the ACIP list updates annually, always confirm with your plan which vaccines are fully covered before scheduling an appointment.
What Is the WISeR Model and Who Will It Affect?
The WISeR Model (Wasteful and Inappropriate Service Reduction) introduces prior authorization requirements to Original Medicare for certain outpatient services — starting January 1, 2026, in:
- New Jersey
- Ohio
- Oklahoma
- Texas
- Arizona
- Washington
Using AI-assisted review, Medicare will flag potentially unnecessary services — but final decisions will still be made by licensed clinicians. If you live in one of these states, you may need pre-approval for services that previously didn’t require it.
How to Prepare for Medicare Changes for 2026
- Review your plan’s Annual Notice of Change (ANOC) as soon as it arrives.
- Check your prescription drug list to see if higher caps or tier changes will affect you.
- If on Medicare Advantage, confirm which SSBCI perks will remain.
- If you live in a WISeR state, ask your doctor’s office about new prior authorization steps.
Need Help Navigating Medicare in 2026?
Skyline Benefit is an independent Medicare insurance broker helping seniors across the U.S. make sense of shifting rules, rising costs, and disappearing benefits. Whether you need help comparing Medicare Advantage plans, navigating Part D drug changes, or preparing for prior authorization requirements, we’ll guide you every step of the way — at no extra cost.
Schedule a consultation today. Call us at: (714) 888-5112