Transition Year Playbook: Keeping Your Prescription Drug Plans Creditable in 2025–2026
Introduction
Change is in the air. As CMS pushes forward with updates to Medicare Part D rules, employer-sponsor plans are entering a delicate “transition zone.” 2025 still allows the old simplified method, while 2026 brings a higher actuarial threshold. That means plans that currently pass may not in future years - unless you act now.
Let’s walk through a playbook for surviving (and thriving) during the transition.
1. Understand the 2025 vs. 2026 Methods
2025: Many non-RDS plans can still use the existing simplified method (60% of drug costs).
2026: CMS is mandating a jump to 72% of drug costs, expanding requirements (e.g. biologics, removing benefit maximums) to align with enhancements under the Inflation Reduction Act. Risk Strategies+2vitacompanies.com+2
For 2026 only, non-RDS plans may choose either method, giving you flexibility (if your plan passes under both). Risk Strategies+1
2. Identify At-Risk Plan Designs
Not every plan will survive the transition. Those at greatest risk include:
High deductible or high cost-sharing designs
Plans barely exceeding the 60% threshold today
Sparse formularies, especially excluding biologics
Plans with limited pharmacy networks
If your plan fits any of those, start adjusting now.
3. Use Technology to Stay Agile
Manual testing or outsourcing for each year gets painful fast. You need a tool that adapts as rules change. Creditable allows you to:
Instantly test plan designs month over month
Generate defensible reports you can reuse
Re-run tests if design changes mid-year
Stay responsive in a shifting regulatory environment
5. What to Watch in Late 2026 & Beyond
2027 may eliminate the old simplified method entirely, making 72% or actuarial testing mandatory
New CMS clarifications may tighten “reasonable access” definitions
Industry pressure to standardize testing tools may rise
If you build a disciplined, transparent approach now, you’ll be best positioned to ride the changes rather than fight them.
Conclusion / Call to Action
The 2025–2026 transition is your window to future-proof your plans. If you wait until renewal time, the changes may force you into scrambling, or worse, non-compliance.
Want help modeling your plans through 2026, stress testing them, or running side-by-side comparisons? Drop us a message or book a demo, and let’s get you ahead of the curve.