The Medicare changes for 2026 bring several updates to how drug coverage, benefits, and care coordination work. From new premiums and deductibles, to spending limits and controversial pilot programs like WISeR, here’s what’s changing—and how to make the most of your Medicare coverage this year.
10 Medicare Changes for 2026
1. 2026 Premiums, Deductibles and Costs are Pending
Currently the 2026 premiums are not official. Here are the projections for 2026 pricing- unofficially calculated based on the CPI-U (Consumer Price Index for all Urban Consumer). We will update this section once these 2026 Medicare premiums, deductibles and costs have become official.
- Part A Premium: Typically Free
- Part A Deductible: $1716 (Projected)
- Part B Premium: $206.50 (Projected)
- Part B Deductible: $288 (Projected)
- Medigap High Deductible Plan G: $2,870 to $2,940 (Projected)
Pricing for the new year is usually available by now and may be delayed due to the current government shutdown (although Medicare and SSA are still staffed during shutdowns). We will provide a dedicated page to 2026 prices that will include official Medicare 2026 costs and premiums including IRMAA thresholds once they are posted.
2. Prior Authorization Pilot for Original Medicare (WISeR Model)
In 2026, Medicare will begin testing a new system for certain medical procedures under Original Medicare, called the WISeR Model, short for Wasteful and Inappropriate Service Reduction. This is the official name of the Prior Authorization Pilot Program that will apply to select services in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
The goal of WISeR is to reduce unnecessary or repetitive services, To do that, Medicare will use prior authorization assisted by Ai technology.
Unlike Medicare Advantage—where prior authorization has long been standard—this will be the first time it’s introduced in Original Medicare. The pilot is scheduled to run for six years, from 2026 through 2031, and will collect data to evaluate whether prior authorization improves efficiency or delays care. Source: CMS.gov.
💡 Senior65 is very concerned about the WISeR pilot. Please check out our editorial thoughts about the risks of using Ai for Medicare prior authorization.
2. Expanded “Extra Help” Program for Low-Income Beneficiaries
The Low-Income Subsidy (LIS), often called “Extra Help,” is a program that assists people with limited income and resources in paying for their Part D premiums, deductibles, and co-payments. The Medicare changes for 2026 significantly expand eligibility for this program.
If you qualify for Medicare’s Extra Help program, your prescription costs are dropping even further in 2026. You’ll pay no more than $5.10 for generics and $12.65 for brand-name drugs per prescription. This expansion helps more people with limited income afford their prescriptions—no coverage gaps, no hidden costs. This means fewer seniors will have to choose between medications and other essentials.
Below are the 2025 income and resource limits used to determine eligibility. If you fall under these amounts, you could receive full or partial Extra Help automatically through Social Security:
| Household Type | Yearly Income (Less Than) | Resources (Less Than) |
|---|---|---|
| Single person | $23,475 | $17,600 |
| Married couple (living together, no dependents) | $31,725 | $35,130 |
💡 Tip: Tip: If your income is modest—even if you were denied before—it’s worth checking again. The limits go up a little every year. You can apply through Social Security at ssa.gov/extrahelp.
3. A New $2,100 Annual Cap on Prescription Drug Costs
Medicare is keeping the new prescription drug spending limit introduced in 2025—but with an adjustment for inflation. In 2026, the maximum out-of-pocket cost for Part D medications will rise slightly to $2,100 per year. Once you reach that amount, your covered prescriptions are $0 for the rest of the year.
While the continued cap gives Medicare enrollees predictable drug spending and extra protection against high pharmacy bills, it has upset the Medicare Part D marketplace for 2026. Most Part D drug providers have changes premiums, adjusted which drugs are covered, and have dropped independent agents from the the Part D enrollment process. Please make sure review your Part D drug coverage and pricing options between Oct 15-Dec 7.
4. Lower Drug Prices Through Medicare Negotiation
For years, the government was prohibited from negotiating the price of prescription drugs. But, another update for 2026 is the rollout of Medicare’s first negotiated drug prices under the Inflation Reduction Act. The goal is to lower what you pay for essential medications without changing your access or quality of care.
The initial list includes 10 of the most common brand-name drugs, covering conditions such as diabetes, heart disease, and cancer: Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and Fiasp / NovoLog (all FlexTouch and PenFill versions). Source: Medicare.gov.
📌These new lower prices will show up automatically at your pharmacy counter.
5. New Preventive and Primary Care Benefits
Medicare is continuing to invest in early care and chronic condition management. In 2026, a new model called Advanced Primary Care Management Services will provide monthly payments to doctors who offer 24/7 access, proactive care coordination, and more personalized follow-up.
The program encourages doctors to focus on prevention instead of reaction—helping patients avoid unnecessary hospital or ER visits. Also new for 2026: expanded colorectal cancer screening coverage, including CT colonography as an approved preventive option.
The catch is that for many of the new primary care services covered under Part B, you still pay 20% of the Medicare-approved amount if you currently do not have a Medigap plan that covers Part B co-insurance.
💡 Don’t let these new benefits surprise you with unexpected bills. Enroll in a Medigap plan to cover that 20% co-insurance risk, ensuring all your new preventive care—and all other Part B services—are fully covered. Click here to get your Medigap quote today.
6. Medicare Prescription Payment Plan (MPPP): Automatic Reenrollment
Medicare Part D plans must offer the Medicare Prescription Payment Plan (MPPP), which lets you spread your out-of-pocket drug costs into monthly payments instead of paying the full price upfront at the pharmacy. In 2026, Participants will be automatically reenrolled each year unless they choose to opt out. This feature helps you spread out your drug costs evenly, so you’re never hit with a big pharmacy bill all at once. Source: CMS.gov.
7. $35 Monthly Insulin Cap Becomes Permanent
Medicare will make permanent the $35 monthly cap on insulin, applying to all covered insulin products under Part D. This rule keeps insulin affordable year-round and removes it from any deductible requirements. Source: Federalregistrer.gov.
8. Vaccines Recommended by ACIP Remain Free
All adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) stay fully covered under Part D—you won’t pay a cent for them. This includes routine and travel-related vaccines such as shingles, RSV, hepatitis, and flu. Source: Federal Register.
9. Restrictions on Certain Medicare Advantage Extra Benefits
Starting in 2026, Medicare Advantage (MA) plans will face new restrictions on supplemental benefits that are not primarily health-related. CMS clarified that items or services unrelated to improving or maintaining health—like non-nutritious food, tobacco, alcohol, or cosmetic enhancements—cannot be offered as plan perks under the Special Supplemental Benefits for the Chronically Ill (SSBCI) category. Source: CMS.
💡 Senior65 Editorial Note: Medicare Advantage Plans can still offer fitness, nutrition, or disease management perks, but not benefits that don’t serve a health purpose. We are not sure which MA plans allowed for Tobacco perks in the first place.
10. Medicare Goes More Digital
Medicare is going paperless for those who choose it. Starting in 2026, beneficiaries can opt in to digital notices and statements through their Medicare.gov account. That means faster access to claims, easier benefit tracking, and no more missing mail.
This move doesn’t affect your coverage—it just makes managing it easier. If you prefer printed materials, you can still request them at any time.
Making the Most of Your Medicare Plan: Next Steps
Understanding the Medicare Changes for 2026 is just the first step; the next is using that knowledge to your advantage. A few small steps can help you get more from your coverage this year:
- Review your Part D plan. Drug formularies and preferred pharmacies can change each January. Compare options during the Annual Enrollment Period (Oct 15–Dec 7).
- Explore Medigap options if you’re on Original Medicare and want more predictable costs. Click here to get a Medigap Instant Quote or click here to check your chances of approval with medical underwriting.
- Create a Medicare.gov account. You’ll get faster updates, track your claims online, and choose digital statements if you prefer paperless management.
- Schedule preventive care early. Take advantage of the expanded cancer screening benefits and wellness visits.
💡 Pro tip: If your needs have changed or you’re unsure about your options, call 800-930-7956. Our Senior65 team can help you compare Medigap plans and confirm you’re getting every benefit available—free of charge.
FAQs: Medicare Changes for 2026
Q: Do I need to change my plan to get the $2,100 drug cap?
A: No. The new out-of-pocket limit applies automatically to all Medicare Part D plans beginning January 1, 2026.
Q: What if I’m new to Medicare in 2026?
A: Welcome! You’ll get these updates automatically if you work with Senior65.com. If you want predictable costs and freedom to see any doctor, consider pairing your Original Medicare with a Medigap plan. You can get an Instant Medigap Quote here or call 800-930-7956 for no-pressure help.
Q: Will my Part B premium go up in 2026?
A: Yes. The government sets this rate each year, and it applies to everyone with Part B, regardless of whether you have Medicare Advantage or Medigap. Check out Change #1 at the top of this article to get the latest info on Medicare’s newest costs and premiums. Medigap plan premiums tend to go up around your birthday rather than on the new year.
Q: Does the new $2,100 cap on drug costs apply to Medicare Advantage plans?
A: Yes, the $2,100 cap applies to all Part D drug coverage, including the drug benefits packaged within Medicare Advantage Plans (MA-PDs).
Q: Do the changes above affect Medigap plans?
A: No direct federal changes to Medigap are expected in 2026. Some states like Rhode Island have made new state specific laws that affect Medigap. Call Senior65.com at 800-930-7956 if you have questions about your state.