CMS Asks How Medicare Part D Should Define Fair Pharmacy Contract Terms

The Centers for Medicare & Medicaid Services (CMS) published a request for information on September 24, 2026, asking pharmacies, insurers, pharmacy benefit managers (PBMs) and the public how Medicare Part D should define “reasonable and relevant” contract terms for pharmacies. Comments are due November 23, 2026. The notice does not change any rule today; it starts the fact-finding for standards that would apply from 2029.

What the notice is, and where it comes from

Part D, Medicare’s outpatient prescription drug benefit, is run by private plan sponsors: standalone prescription drug plans (PDPs) and Medicare Advantage plans that include drug coverage (MA-PD plans). Under existing rules, sponsors must contract with any pharmacy that accepts the sponsor’s standard terms and conditions, and those terms must already be “reasonable and relevant.” According to the notice, CMS “has not established additional requirements for what constitutes reasonable and relevant terms and conditions.”

That changes because of Section 6223(a) of the Consolidated Appropriations Act, 2026. As described in the notice, it requires sponsors of prescription drug plans to let any pharmacy that meets the plan’s standard terms join as a network pharmacy. It also requires that, for plan years beginning January 1, 2029, those standard terms be reasonable and relevant according to standards set by the HHS Secretary. The statute sets the timetable: the RFI must be issued no later than April 1, 2027, and the standards must be established no later than the first Monday in April 2028. CMS is issuing the RFI earlier than that deadline.

What CMS is asking about

The notice is a long list of questions rather than a proposal. CMS asks respondents to identify which section they are answering and to supply quantitative data, de-identified contract language and evidence on enrollee access where they can. The main topics are:

• Reimbursement and dispensing fees: whether payments cover pharmacies’ ingredient and operating costs; how rates compare with actual acquisition costs; how maximum allowable cost (MAC) lists are set and updated; “lesser of” pricing and usual-and-customary prices; and the link, if any, between reimbursement and “pharmacy deserts.”
• Aggregate guarantees: CMS asks how far the price shown on a claim differs from what a pharmacy is finally paid after end-of-year reconciliation, and whether guarantees that cover both Part D and commercial business can shift money between the two.
• Contracting practices: how sponsors decide which pharmacies are “similarly situated,” whether any-willing-pharmacy terms apply to preferred networks or only non-preferred ones, how specialty pharmacy status is assigned, and whether common ownership between a PBM and a specialty pharmacy plays a role.
• Contract mechanics: how long pharmacies get to review terms, the use of “deemed acceptance” when a pharmacy does not respond, mid-contract changes to rates or MAC lists, and whether pharmacies see complete reimbursement information when a contract is offered.
• Quality measures and audits: which performance measures are used and whether they affect payment or network placement, plus audit frequency, extrapolation methods and recoupment of payments for minor errors.
• Dispute resolution, recoupment and termination: what appeals exist and how often they succeed.

CMS also asks how the new standards would interact with the PBM disclosure requirements and remuneration restrictions in section 1860D-12(h) of the Social Security Act, and how the Inflation Reduction Act’s negotiated maximum fair prices have affected pharmacy reimbursement terms.

What the document does and does not establish

An RFI collects input; it sets no standard, and it contains no findings. The notice says it is “issued solely for information and planning purposes” and that CMS will not answer questions about the policy issues it raises. Many of the questions are open-ended (“whether CMS should establish reimbursement methodologies or rates as part of the standards”), so the notice does not reveal which way the agency leans. It does show which practices CMS considers worth examining, including reconciliation after the point of sale, deemed acceptance of contract changes and PBM-affiliated pharmacies.

What remains unknown

• Whether the standards will set reimbursement floors or methods, or will focus on process and transparency.
• How CMS will define “reasonable and relevant” across retail, mail-order, specialty, long-term care and other pharmacy types.
• What the standards will mean for patients’ out-of-pocket costs, pharmacy choice and preferred-network status. The notice asks about access and outcomes but reports no data on them.
• How any standards will be enforced, and what documentation sponsors will have to provide. CMS asks for input on this without stating a plan.
• Whether the rulemaking that follows will keep the 2029 start date.

Why it matters beyond pharmacy contracts

People on Medicare rarely see the contracts between their plan’s PBM and their pharmacy, yet those terms can affect which pharmacies stay in a network and what a pharmacy can afford to stock. The notice explicitly asks whether reimbursement policies influence decisions to stock high-cost drugs, and how reimbursement relates to pharmacy deserts in rural and underserved areas. Whatever standards emerge, the comment record built in the next two months is the evidence CMS says it will use. Anyone can file comments at regulations.gov under docket CMS-2026-3037 (file code CMS-4217-NC) until November 23, 2026.

This article provides general information, not medical or legal advice.

Source: Centers for Medicare & Medicaid Services, “Request for Information; Medicare Part D Reasonable and Relevant Pharmacy Contracting Standards,” Federal Register, September 24, 2026 (91 FR 60568). Read the notice on FederalRegister.gov.