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On April 7, 2025, the Centers for Medicare and Medicaid Services (CMS) released the Final Part D Redesign Program Instructions for 2026, detailing changes from the Inflation Reduction Act of 2022 that affect employer-sponsored prescription drug coverage.
Creditable Coverage
Employers offering prescription drug coverage to Medicare Part D-eligible individuals must notify them and CMS if their coverage is creditable, meaning it meets or exceeds Medicare Part D standards. CMS’ existing guidance provides several methods for determining creditable coverage:
- Employers with insured prescription drug plans should confirm with carriers if the coverage is creditable.
- For self-insured plans or if no creditable coverage determination is made, a simplified method can be used if design requirements are met; otherwise, an actuarial method is needed.
Revised Simplified Determination Method
CMS is finalizing a new method to align with the enhanced Part D benefits under the IRA, as detailed in its Draft Part D Redesign Program Instructions. Under the new guidelines, group health plans must cover at least 72% of prescription drug costs to qualify as creditable coverage, up from 60%.
Creditable Coverage Determinations for 2025 and 2026
CMS will allow the use of the simplified determination method for 2025 for group health plan sponsors not applying for the retiree drug subsidy (RDS).
In 2026, non-RDS group health plans can choose between the existing or revised simplified determination methods to assess if their prescription drug coverage is creditable.
Enforcement
Employers face no penalties for offering non-creditable prescription drug coverage, which can still benefit employees. However, it's crucial for individuals to know if their coverage is creditable. Medicare-eligible individuals with non-creditable coverage who delay enrolling in Part D may incur higher premiums later.
Download the bulletin for more details.
CMS Resources
