CMS is pitching new guardrails for pharmacy benefit managers and Medicare Advantage plans under a proposed rule released Oct. 16.
The proposed rule would implement sections of the Consolidated Appropriations Act of 2026. Comments are due Dec. 15.
Here are eight things to know from the proposed rule:
- Starting Jan. 1, 2028, PBMs and their affiliates would only be able to accept flat-dollar, itemized service fees for Part D drugs. The fees could not depend on drug prices or rebates. Manufacturer rebates and discounts would remain allowed if they are fully passed through to the plan sponsor.
- The proposed rule would define fair market value for service fees as the cost of the itemized service, along with a reasonable markup.
- Beginning in contract year 2028, MA organizations would need to estimate “a letter grade” for their provider directory accuracy based on a provider sample. In 2029, CMS would publicly post these scores, and plans would need to show them in their directories.
- If an MA enrollee books a provider listed as in network, that enrollee would pay no more than the lesser of the in-network or other cost-sharing. This would still apply if the provider ends up being out of network. That protection would begin in contract year 2028.
- MA organizations would need to verify provider directory data at least every 90 days, and they would need to check the data for hospitals and other facilities at least once each year.
- Full-benefit dual-eligible enrollees with Medicare and Medicaid who are at or below 100% of the federal poverty level would have $0 copays for generic drugs starting in plan year 2028. Currently, the copays for this population are set at $1, indexed to inflation ($1.60 in 2026).
- PBMs would need to disgorge remuneration that is not allowed under the Consolidated Appropriations Act to the Part D plan sponsor, and sponsors would then have to pass those funds on to CMS.
- PBMs would have to allow Part D plan sponsors to audit them at least once a year, if requested.
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