A new CMS proposal brings flat service fees, expanded reporting and directory accuracy grades to Medicare Advantage and Part D, starting in 2028.
On October 16, CMS proposed a rule that puts key pieces of the Consolidated Appropriations Act of 2026 into practice, as Modern Healthcare reported. The theme is clarity. Pharmacy benefit managers serving Medicare would move to flat service fees and report more data each year. Medicare Advantage plans would grade the accuracy of their provider directories.
For plan sponsors, the signal is simple: pharmacy spend is becoming easier to see, measure and predict. Commercial buyers tend to follow where Medicare leads, so this rule is worth watching well beyond Medicare.
A simpler fee model for pharmacy services
Beginning in 2028, PBMs serving Medicare Advantage and Part D would earn flat, fair market value service fees. Those fees would stay independent of a drug’s price, manufacturer rebates and other price concessions. Rebates keep flowing, with their full value passed through to the plan sponsor, according to a Crowell & Moring analysis.
The market is already heading this direction. In May, Optum Rx announced a fee-based model with monthly per member fees, as reported by Healthcare Finance News. CMS is codifying a shift the industry has already started.
More data in sponsors’ hands
PBMs would report annually to plan sponsors and CMS on drug prices and utilization, formularies and pharmacy payments, the Crowell & Moring analysis notes. That gives plan sponsors a clearer view of where each pharmacy dollar goes. CMS says it needs more data on current contract structures before it can estimate the financial impact, per Fierce Healthcare.
Provider directories get a report card
Starting in 2028, Medicare Advantage plans would verify their directories every 90 days and assign each one a grade from A through F. The grade reflects network status, current phone and address details, and telehealth availability. Plans would also identify providers they own or control.
Grades go public in 2029, when CMS would begin publishing them. If a directory lists a provider as in-network by mistake, the member pays in-network cost sharing.
Accurate provider data matters well beyond directories. Every conversation about a prescription depends on reaching the right physician at the right practice.
The next savings opportunity sits with the prescriber
As PBM fees become flat and predictable, the next lever sits upstream, at the moment a prescription is written. Nearly half of people call their doctor when a medication costs too much. Physicians already hear from payers: in the RazorMetrics 2026 Physician Drug Cost Survey, 71% said PBMs or plan sponsors reach out at least occasionally. Yet 44% review that outreach and rarely act on it, and 49% want fewer interruptions to their workflow.
Outreach works when it fits how physicians already practice. RazorMetrics works alongside every PBM, delivering clear, prescriber-ready recommendations inside the physician’s existing workflow. The result is a 76% physician response rate, a flat per member per month fee, and savings that complement the work PBMs already do.
Key dates
- October 16, 2026: CMS releases the proposed rule
- 60 days after Federal Register publication: public comments due
- 2028: flat PBM fees, annual reporting, 90-day directory checks and cost sharing protections begin
- 2029: directory grades go public
The rule may change after public comment. The direction is clear: Medicare is building a pharmacy system that is simpler to see and easier to predict. Plan sponsors who pair that transparency with prescriber-level savings will capture the most value.
