CMS’s 2026 Rule and Its Impact on Medication Therapy Management

For more than a decade, Medication Therapy Management (MTM) programs have been judged by a narrow scorecard: completing annual comprehensive medication reviews, boosting adherence in key drug classes (diabetes, hypertension, and cholesterol medications), and improving statin use among patients with diabetes. Those metrics still matter. But the Contract Year 2026 Medicare Advantage and Part D Final Rule will reshape the incentives and the context around them. By codifying the Inflation Reduction Act’s insulin and vaccine protections, launching the Prescription Payment Plan at the pharmacy counter, recalibrating Star Ratings, and signaling a pivot from process to outcomes, The Centers for Medicare and Medicaid Services (CMS) is steering MTM toward a higher bar of demonstrating real impact in preventing harm, avoiding unnecessary costs, and addressing disparities in care.¹

The 2026 rule arrives at a moment when Medicare is fine-tuning both the financial and clinical levers of pharmacy care. Beyond setting benefit design, CMS is weaving new patient protections into the fabric of daily operations, embedding patient protections into operational workflows that shape what care looks like at the pharmacy counter and in the wider healthcare system. The rule signals a new alignment of medication access, affordability, and accountability, rather than just another layer of regulation.

Sustained adherence and safe medication use matter more to outcomes than performance on surveys.

How well patients take and manage their medicines will matter more than patient surveys when it comes to Star Ratings as patient experience and access measures, which used to carry a weight of 4, will now count for only 2. That shift gives medication measures more influence than before.² For Part D, the familiar lineup remains: medication adherence for diabetes, hypertension treated with RAS antagonists, and cholesterol management with statins, each weighted at 3; statin use in persons with diabetes; Medicare Plan Finder price accuracy; and completion of comprehensive medication reviews, each weighted at 1.³

MTM eligibility is stretching even further in 2026

Last year, plans had to include all 10 core chronic conditions (including HIV/AIDS) when deciding who qualifies, and they now count all Part D maintenance drugs in that calculation. CMS also tied the spending threshold to the average annual cost of eight generics, making the bar more realistic. For 2026, that threshold drops from $1,623 to $1,276, which means more Medicare beneficiaries will qualify for MTM services, and more patients will have access to pharmacist-led reviews that can prevent harm and improve outcomes.⁴

The Prescription Payment Plan becomes part of the daily pharmacy workflow

Beginning in 2026, pharmacies and health plans must flag patients at the counter who are likely to benefit from the new payment option, particularly anyone facing a $600 out-of-pocket charge for a single prescription.¹ These claims will be routed using a special identifier specific to the Medicare Prescription Payment Plan (MPPP), while real-time benefit tool prices remain unchanged so patients still see the full drug cost. For MTM teams, these triggers provide new insight into financial stress points and create timely opportunities for pharmacists to step in with counseling before a patient becomes nonadherent.

As more patients qualify, MTM success shifts from counting reviews to the speed and precision of outreach.

Insulin and vaccines will remain protected in 2026

CMS confirmed that adults will continue to get vaccines at no cost under the Inflation Reduction Act (including flu, pneumonia, and shingles) and capped insulin out-of-pocket costs at the lower of $35 or 25% of either the negotiated price or the maximum fair price.¹ These protections reduce financial strain and make it more likely that patients will stay on therapy, a critical piece for MTM programs working to improve adherence and deliver long-term health outcomes.³

Steps MTM Teams Can Take as New Rules Roll Out

As the 2026 rules take effect, medication therapy management will need to focus less on the volume of completed medication reviews and more on how quickly they reach the right patients. With the cost threshold lowered to $1,276, thousands of additional beneficiaries will now qualify, and those eligibility signals will arrive faster than before. In this new environment, the measure that matters most is speed, both in contacting patients once they qualify and in completing a CMR or TMR.⁴

Under the new Prescription Payment Plan, a $600 bill at the counter automatically triggers a flag that the patient is “likely to benefit.” Pharmacies are required to provide patients with a “Likely to Benefit Notice,” process the claim through the special “MPPP” channel, and manage any reversals. CMS has made it clear that plans cannot impose new fees for this work.¹ A retrospective study found that patients were more likely to abandon an oral anticoagulant prescription when their out-of-pocket cost was greater than $100, which emphasizes how strongly cost influences whether patients pick up their medications.⁵

For MTM teams, the task is to build smooth, reliable workflows around these moments so pharmacists can step in quickly to pair cost smoothing with counseling, affordable alternatives, or synchronized refills.

This shift reflects CMS’s broader goal of weaving fairness and access into the fabric of Star Ratings, with risk adjustment for Part D adherence measures set to phase in by 2028. The intent is to account for the reality that not all patients face the same barriers. Low-income enrollees, those dually eligible for Medicaid, people living in rural areas, or patients with limited English proficiency often have steeper challenges when it comes to staying on therapy.

The shift in Star Ratings pushes MTM teams to innovate, proving care can reach patients in ways that are both fair and effective.

For MTM teams, this means segmenting performance and outreach in new ways that many have not considered before, made far more efficient and achievable when pharmacists integrate AI . The focus shifts from checking a compliance box to ensuring that the patients who need support most actually receive it in ways that work for them. Programs able to adapt outreach, counseling, and follow-up will be best positioned to demonstrate value across the full breadth of the Medicare population.