2026 Medicare Part D Drug Changes You Can’t Ignore

Must-know for Medicare open enrollment: the $2,100 cap, smoothing — and the self-administered drug trap

Open enrollment runs Oct. 15 - Dec. 7. Your 2026 playbook needs three pivots that hit adherence, scheduling and cash flow.

A real ceiling on drug spend
🔹 Part D out-of-pocket costs cap at $2,100 in 2026, up from $2,000 in 2025. After patients hit it, they owe $0 for covered Part D drugs — fewer catastrophic drop-offs in oncology, rheum, neuro and transplant.
🔹 Smoothing kills sticker shock
Patients can opt in to pay $0 at the counter and spread cost share into predictable monthly bills. Plans pay pharmacies, then bill members — a financing mechanism, not a discount. Train teams now.
🔹 The overlooked budget bomb
Self-administered drugs pulled from facility stock in a hospital outpatient department aren’t covered by Part B and Part D can’t be billed in real time. Result: the patient may pay the hospital, then submit to Part D for reimbursement. That time gap drives abandonments and bad debt. Tighten pre-service counseling.

Clinic to-dos before Jan. 1
 • Refresh PA rules and formulary paths for your top MA-PD plans
 • Script staff on the $2,100 cap and smoothing enrollment
 • Pre-run benefits for high-cost starts and line up on-pathway alternatives
 • Capture product-level plan data at scheduling, not at check-out
 • Pharmacies or MID providers are required to notify participants of this program if they have a prescription that costs more than $600 per fill.

Watchouts
 • Smoothing applies only to covered Part D drugs. If a denial is overturned on appeal, then it counts toward the cap.
 • Past-due balances can block re-election when switching within the same sponsor — don’t promise automatic eligibility.

Patients must opt into the program directly through their specific Part D plan. They can do this by visiting the plan's website, calling them directly, or submitting a paper request form, but there is no single national application.

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