What is Medicare Part D? - Budget Seniors

Key Takeaways: Medicare Part D in 2026 💡

What is Medicare Part D? It’s voluntary prescription drug insurance offered through private companies, covering brand-name and generic medications under a plan-specific drug list called a formulary.

Is Medicare Part D really necessary? Practically, yes — even if you take no medications now. Delaying enrollment triggers a permanent late penalty of 1% per uncovered month added to your premium for life.

What’s the difference between Part D and Part B? Part B covers drugs administered by a doctor in clinical settings (injections, infusions). Part D covers drugs you pick up at the pharmacy and take on your own.

What doesn’t Part D cover? Weight-loss drugs (with a potential policy shift coming), erectile dysfunction medications, over-the-counter products, cosmetic drugs, and prescription vitamins.

What drugs are covered? Each plan’s formulary varies, but all must cover drugs in six protected classes including antidepressants, antipsychotics, anticonvulsants, cancer drugs, HIV/AIDS drugs, and immunosuppressants.

Is Medicare Part D free? No. The average standalone premium is $34.50/month in 2026, plus a maximum deductible of $615 — though many plans charge less or nothing.

Who is eligible? Anyone with Medicare Part A or Part B who is a U.S. citizen or lawful resident — regardless of income, health status, or pre-existing conditions.

What’s the 2026 out-of-pocket cap? You pay a maximum of $2,100 for covered drugs, then $0 for the rest of the year — a protection that didn’t exist before 2025.

What are the best Part D plans? Centene (Wellcare) and Humana earned the top 2026 ratings from U.S. News, with Wellcare offering the lowest average premiums.

How do I find the right plan? Use the Medicare Plan Finder at Medicare.gov — enter your drugs, pharmacy, and zip code to compare real costs across every available plan in your area.

💊 1. Medicare Part D is Voluntary Prescription Drug Insurance — But Skipping It Could Cost You Thousands

Let’s cut through the confusion right at the start. Medicare drug coverage (Part D) is extra coverage people with Medicare can choose to help lower costs of prescription drugs, offered through Medicare-approved private plans. It’s not built into Original Medicare automatically — it’s a separate, optional layer of coverage that you actively choose to add.

Here’s the critical distinction most people miss: Original Medicare (Parts A and B) provides essentially zero outpatient prescription drug coverage. Part A covers some drugs administered during hospital stays, and Part B covers a limited number of drugs given in doctor’s offices (like certain chemotherapy infusions), but the pills, inhalers, insulin pens, and patches you pick up at your local pharmacy? Those are exclusively Part D territory.

You get Part D coverage one of two ways: through a standalone Prescription Drug Plan (PDP) that supplements your Original Medicare, or through a Medicare Advantage plan (Part C) that bundles drug coverage into your medical plan. The vast majority of Medicare Advantage plans for individual enrollment (89%) include prescription drug coverage, so most Part C enrollees already have Part D baked in.

Part D Basics	Details	💡 What You Need to Know
What it covers	Outpatient prescription drugs	Brand-name, generic, biosimilars, vaccines 💊
Who offers it	Private insurance companies	CMS-approved, federally regulated 🏛️
How you get it	Standalone PDP or bundled in Part C	Can’t have both simultaneously ⚠️
Is it required?	Technically no	But the late penalty makes it practically mandatory 🚨
Formulary	Plan-specific drug list	Check yours annually — it changes every year 📋
Out-of-pocket cap	$2,100 in 2026	After this, covered drugs cost $0 all year ✅

💡 Critical Insider Tip: Even if you’re perfectly healthy and take zero prescriptions at age 65, enrolling in Part D when you’re first eligible is one of the smartest financial decisions you can make. The Part D late enrollment penalty is calculated by multiplying 1% times the national base beneficiary premium ($38.99 in 2026) times the number of full uncovered months you were eligible but didn’t enroll. Wait just five years and you’re looking at an extra $23+ per month tacked onto your premium permanently — for the rest of your life.

⚖️ 2. Yes, Medicare Part D is Essentially Necessary — The Penalty Alone Makes It a Non-Negotiable

This is the question that trips up thousands of new Medicare beneficiaries every year: “I don’t take any medications, so why would I pay for drug coverage I don’t need?”

The mathematical reality is brutal. The late enrollment penalty isn’t a one-time fee — it’s a permanent surcharge that compounds the longer you wait. If you go 63 days or longer without creditable prescription drug coverage after your initial enrollment period, you have to pay a late enrollment penalty that is permanently added to your monthly Part D premium for as long as you have Medicare drug coverage, even if you switch plans.

But beyond the penalty, consider this: the average American over 65 takes 4-5 prescription medications. Health conditions develop unpredictably, and drug costs without insurance can be staggering. A single brand-name medication can cost hundreds or thousands per month out-of-pocket.

Scenario	Without Part D	With Part D (2026)	💡 The Difference
Monthly premium	$0	~$34.50/month average	Small investment for massive protection 💰
Late penalty (5-year gap)	$23.39/month extra — forever	$0 penalty	Penalty never goes away 🚫
Annual drug spending cap	None — unlimited exposure	$2,100 maximum	One hospitalization could save thousands 🛡️
Insulin costs	Full retail ($300-$900/month)	$35/month cap	Life-changing savings for diabetics 💉
Negotiated drug prices	Not available	10 drugs at reduced prices in 2026	Savings on cancer, heart, diabetes meds 📉
Vaccine costs	Varies widely	$0 for all recommended vaccines	Shingles, flu, pneumonia — all covered 🩹

There’s exactly one exception to the penalty: if you had creditable drug coverage from another source (like an employer plan, TRICARE, or VA benefits) that was at least as good as standard Part D coverage. If you did, you won’t owe a penalty when you eventually enroll. Your employer or plan administrator is required to notify you each year whether your coverage qualifies as creditable.

Discover Free Senior Landline Phones

💡 Critical Insider Tip: The penalty rate is calculated based on the national premium rate for the current year, multiplied by the number of months you did not enroll when eligible, and this can add up — if the premium goes up or down, your penalty changes too. This means the penalty isn’t static. As Medicare’s base premium rises over time, your penalty amount rises with it.

🔬 3. Part D Covers Pharmacy Drugs, Part B Covers Clinic-Administered Drugs — And the Financial Gap Between Them is Enormous

This is one of the most misunderstood distinctions in all of Medicare, and getting it wrong can cost you hundreds or thousands of dollars at the pharmacy counter.

Medicare Part B covers medications that are typically administered in a clinical setting — think chemotherapy infusions at an oncology center, injectable osteoporosis drugs given at your doctor’s office, or immunosuppressants delivered through an IV. Part B usually covers drugs you wouldn’t typically give to yourself, like those you get at a doctor’s office or in a hospital outpatient setting.

Medicare Part D covers everything else — the prescriptions you fill at a retail or mail-order pharmacy and take on your own at home. This includes pills, capsules, inhalers, insulin pens, eye drops, topical creams, and patches.

Here’s where it gets financially significant: the $2,100 Part D out-of-pocket cap does not cover drugs covered under Medicare Part B, such as injectables and infused drugs, and does not apply to your monthly Part D plan premiums. These are tracked under completely separate spending systems.

Feature	Medicare Part B (Medical)	Medicare Part D (Prescription)	💡 Why It Matters
What it covers	Drugs given in clinical settings	Drugs you take at home	Different benefit, different costs 💊
Cost-sharing	20% coinsurance (no cap under Original Medicare)	Copays/coinsurance up to $2,100 cap	Part D has a spending cap; Part B doesn’t 🛡️
Examples	Chemo infusions, injected biologics, dialysis drugs	Pills, inhalers, insulin pens, patches	Some drugs have both B and D versions ⚕️
Where you get them	Doctor’s office, hospital, infusion center	Pharmacy, mail-order	Location determines which part pays 🏥
Premium	$202.90/month (2026)	Average $34.50/month (standalone)	You may pay both premiums 💸
Deductible	$283/year	Up to $615/year	These are separate deductibles ⚠️
Annual out-of-pocket cap	None under Original Medicare	$2,100	Part B’s unlimited exposure is the bigger risk 😱

💡 Critical Insider Tip: Some medications exist in both injectable (Part B) and oral (Part D) forms. For instance, certain cancer treatments are available as both infusions and pills. The pill version covered under Part D benefits from the $2,100 annual cap, while the infusion under Part B has no spending ceiling in Original Medicare. Always discuss with your oncologist or specialist whether an oral alternative exists — it could save you thousands through the Part D cap alone.

🚫 4. Medicare Part D Has a Lengthy Exclusion List — And Weight-Loss Drugs Remain in Regulatory Limbo

This is the section that catches seniors off guard at the pharmacy counter. Medicare Part D does not publish one universal list of excluded drugs — instead, Medicare requires plans to exclude entire categories, such as drugs used for weight management, cosmetic purposes, or erectile dysfunction.

These exclusions are written into federal law and cannot be overridden by any individual plan, no matter how comprehensive. Even if your doctor writes a prescription, Part D legally cannot cover drugs in these categories for their excluded purposes.

Drugs and categories Part D cannot cover by law:

Weight-loss and weight-management medications (Ozempic for weight loss, phentermine, etc.)
Erectile dysfunction drugs (Viagra, Cialis — unless prescribed for pulmonary hypertension)
Cosmetic drugs (hair growth agents, skin bleaching — except for psoriasis, acne, rosacea, or vitiligo treatments)
Over-the-counter medications (even when prescribed by a doctor)
Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
Cough and cold symptom relief drugs
Drugs used for fertility
Drugs not approved by the FDA as safe and effective

Excluded Category	Common Examples	Any Exceptions?	💡 What to Do
Weight loss/management	Ozempic (for weight loss), Wegovy, phentermine	Covered if prescribed for another condition (e.g., type 2 diabetes, cardiovascular risk)	Ask your doctor about alternative indications 🩺
Erectile dysfunction	Viagra, Cialis, Levitra	Generic sildenafil may be covered for pulmonary hypertension	Explore manufacturer discount programs 💰
Cosmetic drugs	Rogaine (prescription), skin lighteners	Psoriasis, acne, rosacea treatments ARE covered	Confirm the diagnosis code on your prescription 📋
Over-the-counter drugs	Claritin, Miralax, Tylenol	Higher-dose prescription-only versions may qualify	Ask about Rx-strength alternatives 💊
Vitamins/minerals	Multivitamins, iron supplements	Prenatal vitamins and fluoride are covered	Some Part D plans offer OTC allowance cards 🛒
Cough/cold remedies	Codeine cough syrup, Benzonatate	May be covered for non-cough/cold indications	Check your plan’s specific formulary ✅

Here’s the emerging development to watch closely: CMS has re-evaluated the exclusion of weight-loss drugs and proposed to reinterpret the statute to permit coverage of anti-obesity medications for the treatment of obesity when such drugs are indicated to reduce excess body weight for individuals with obesity. Additionally, the Trump administration is planning to launch a temporary, voluntary model to expand Medicare coverage of GLP-1s to treat obesity beginning in 2027. This could be a game-changer for millions of Medicare beneficiaries struggling with obesity — but it’s not in effect yet.

Discover Burial Insurance vs. Pre-Paid Funerals

💡 Critical Insider Tip: If you choose to pay for a medication that is not covered by your prescription drug plan, your payment will not apply toward the Part D out-of-pocket cap. This means money spent on excluded drugs doesn’t count toward your $2,100 maximum — it’s truly out-of-pocket with zero benefit to your annual spending limit. Budget accordingly.

📋 5. Part D Must Cover Drugs in Six Protected Classes — But Every Other Medication Depends on Your Plan’s Formulary

Here’s where the rubber meets the road for most seniors: just because you have Part D doesn’t mean your specific medication is covered. Each plan maintains its own formulary — a curated list of covered drugs that can differ dramatically from plan to plan.

A formulary is an inventory of all the generic and brand-name prescription drugs covered by a Medicare drug plan, and all plans generally must cover at least 2 drugs per drug category, but each individual plan can choose which drugs it will offer.

However, there are six protected classes where CMS mandates significantly broader coverage. Plans are required to cover medications that fall into one of the six protected classes: immunosuppressant (organ transplant), antiretroviral (HIV/AIDS), antidepressant, antipsychotic, anticonvulsant (seizures), and antineoplastic (cancer). Within these classes, plans must cover substantially all available medications — not just two.

Most plans organize their formulary into five cost tiers that determine what you pay:

Drug Tier	What’s Included	Typical 2026 Cost	💡 Money-Saving Strategy
Tier 1: Preferred Generic	Lowest-cost, most common generics	$0 – $5 copay	Always ask if a Tier 1 option exists 💰
Tier 2: Generic	Other commonly used generics	$5 – $20 copay	Still much cheaper than brand-name 💊
Tier 3: Preferred Brand	Brand-name drugs without generic equivalent	$30 – $50 copay	Check if a Tier 1-2 therapeutic alternative works 🔄
Tier 4: Non-preferred	Higher-cost brand-name or non-preferred generics	$50 – $100 copay or 25-40% coinsurance	Request a tier exception through your doctor 📝
Tier 5: Specialty	Very high-cost, complex medications	25-33% coinsurance	The $2,100 cap limits your total annual exposure 🛡️

Beyond tiers, plans impose additional access controls on certain medications. Drugs that require prior authorization, step therapy, or quantity limits are indicated on the formulary, and you can ask your plan to make an exception to coverage rules, including waiving prior authorization, step therapy, and quantity limit restrictions.

And here’s the 2026 landmark development: all Part D enrollees now have coverage of all 10 drugs selected for Medicare price negotiation, including all dosage forms and strengths, and access to several doses and forms of 9 of the first 10 drugs has improved since 2025.

The 10 drugs with negotiated prices for 2026 treat diabetes, heart disease, blood clots, autoimmune conditions, and cancer — including blockbuster medications like Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and Fiasp/NovoLog insulin products.

💡 Critical Insider Tip: Formularies change every January, and plans can also make mid-year adjustments. Pharmacists and doctors update the drug lists each year based on the latest medicine and treatment information. If a drug you rely on gets dropped, moved to a higher tier, or gains new restrictions, you have the right to request a formulary exception — and if denied, you can file a formal appeal.

💲 6. Medicare Part D is Not Free — But 2026 Premiums Are Actually Dropping

The good news: Part D costs are trending downward in several key categories for 2026, thanks largely to the Inflation Reduction Act’s structural reforms. The bad news: “not free” still means multiple layers of costs that add up.

The average stand-alone Part D plan total premium is projected to decrease to $34.50 in 2026, down $3.81 from 2025. The average Part D total premium for Medicare Advantage plans with prescription drug coverage is projected to decrease to $11.50 in 2026, down $1.82 from 2025.

2026 Part D Cost	Amount	Key Details	💡 Insider Context
Average standalone premium	$34.50/month	Decreased from 2025	Some plans offer $0 premiums 📉
Average MA-PD premium	$11.50/month	Also decreased from 2025	Bundled plans are often cheaper 🔗
Maximum annual deductible	$615	Many plans charge less or $0	Not all plans require a deductible ✅
Out-of-pocket maximum	$2,100/year	Increased $100 from $2,000 in 2025	After this, covered drugs are $0 all year 🎯
Insulin cap	$35/month	No deductible applies	Covers all Part D covered insulin products 💉
Vaccine costs	$0	All ACIP-recommended vaccines	Includes shingles, flu, pneumonia, RSV 🩹
Late enrollment penalty	~$0.39/month per uncovered month	Permanent addition to premium	Based on $38.99 national base premium ⚠️
IRMAA surcharge (high income)	Varies by income bracket	Starts at $109,000 individual income	Based on tax returns from 2 years prior 💸

As part of the Inflation Reduction Act, Medicare Part D enrollees enjoy the security of a $2,100 cap on out-of-pocket prescription drug costs in 2026, including any deductibles, copays and coinsurance paid, but not premiums. Once you reach that threshold, your plan covers 100% of covered medication costs for the remainder of the calendar year.

Discover How to Save on Groceries for One

💡 Critical Insider Tip: Wellcare sells the cheapest Part D plans for 2026, with an average of $8 per month, which is $54 less than the national average of $62 per month. Premium alone shouldn’t drive your decision — a $0 premium plan with higher copays could cost more than a $30/month plan with lower copays if you take multiple medications. Always calculate your total annual cost (premiums + deductible + drug copays) using the Medicare Plan Finder.

✅ 7. Anyone With Medicare Part A or Part B Can Enroll — No Health Screening Required

Part D eligibility is refreshingly straightforward compared to many other insurance programs. If you’re enrolled in Medicare Part A and/or Part B, you’re eligible for Part D prescription drug coverage — regardless of income or health status. No physical exams required and you can’t be denied coverage due to health conditions.

This means there’s no underwriting, no medical questionnaires, and no pre-existing condition exclusions. If you have Medicare, you qualify. Period.

Eligibility Requirement	Details	💡 Common Mistake
Medicare enrollment	Must have Part A or Part B (or both)	Having only Part A is sufficient — you don’t need both 📋
Citizenship/residency	U.S. citizen or lawful resident	Must be lawfully present in the country 🇺🇸
Age requirement	65+ or qualifying disability/condition	Under-65 with SSDI for 24+ months, ALS, or ESRD qualify ♿
Service area	Must live in the plan’s geographic area	Plans vary by zip code — always check availability 🗺️
Health status	No restrictions whatsoever	Cannot be denied for pre-existing conditions ✅
Income limits	None — all income levels eligible	Low-income beneficiaries may qualify for Extra Help 💰

Enrollment windows you cannot afford to miss:

Initial Enrollment Period (IEP): 7 months surrounding your 65th birthday (3 before, birthday month, 3 after)
Annual Election Period: October 15 – December 7 each year (changes effective January 1)
Medicare Advantage Open Enrollment: January 1 – March 31 (can switch MA plans or return to Original Medicare + PDP)
Special Enrollment Periods: Triggered by qualifying life events like moving, losing coverage, or institutional changes

💡 Critical Insider Tip: Many people don’t realize that you must have either Part A or Part B to be eligible for a Part D plan — not necessarily both. If you’re still working at 65 and only enrolled in premium-free Part A while keeping employer coverage for medical, you could still add a Part D plan. However, if your employer provides creditable drug coverage, you may not need to — just make sure you get that annual creditable coverage letter from your employer and keep it.

🔍 8. The Medicare Plan Finder is Your Most Powerful Tool — But Most People Use It Wrong

The official Medicare Plan Finder at Medicare.gov is genuinely one of the most useful tools the federal government has ever built for consumers. It lets you enter your specific medications, preferred pharmacy, and zip code to compare every Part D plan available in your area — with personalized cost estimates down to the dollar.

But here’s what trips people up: they compare premiums alone instead of total estimated annual costs. A plan with a $0 premium but a $615 deductible and higher copays could cost you $2,000 more per year than a plan with a $30 monthly premium that waives the deductible and charges lower copays for your specific drugs.

How to use the Plan Finder effectively:

Step	What to Do	💡 Pro Move
1. Gather your drug list	List every medication with exact dose and quantity	Include drugs you might need — not just current ones 📝
2. Know your pharmacy	Identify preferred and backup pharmacies	Mail-order pharmacies often save 10-20% 📦
3. Enter your zip code	This determines plan availability	Plans vary dramatically by county 🗺️
4. Compare TOTAL annual cost	Look at premiums + deductible + estimated drug costs	Don’t just sort by lowest premium — sort by total cost 💰
5. Check star ratings	Prioritize 4-star and 5-star plans	Higher ratings = better service and fewer denials ⭐
6. Verify your drugs on the formulary	Confirm tier placement and restrictions	A drug might be covered but on a high-cost tier ⚠️
7. Review prior authorization rules	Check which drugs need pre-approval	Surprise denials at the pharmacy are avoidable 🚨

💡 Critical Insider Tip: You’ll have a special election period in 2026 if you used the Medicare plan finder tool to select a Medicare Advantage plan but found out the directory contained errors and your preferred healthcare professionals and facilities aren’t in network. This new protection applies specifically to directory inaccuracies — if the plan finder told you something that turned out to be wrong, you have recourse.

📊 9. How to Confirm You Have Part D Coverage — And Why Your Medicare Card Won’t Tell You

A surprising number of Medicare beneficiaries aren’t sure whether they have Part D coverage, especially those whose drug coverage is embedded in a Medicare Advantage plan. Here’s how to verify:

Five ways to confirm your Part D enrollment:

Method	What to Look For	💡 Details
Your plan’s member ID card	Look for “Rx” or “Part D” labeling	MA-PD plans show drug coverage on the same card 💳
Medicare.gov account	Log into MyMedicare.gov	Shows current enrollment, plan name, and coverage dates 🖥️
Call 1-800-Medicare	Request enrollment verification	Available 24/7 at 800-633-4227 (TTY: 877-486-2048) 📞
Your Evidence of Coverage	Annual plan document mailed each fall	Lists every drug benefit, formulary, and cost detail 📄
Explanation of Benefits (EOB)	Sent monthly after filling prescriptions	Tracks your spending toward the $2,100 cap 📊

If you have a Medicare Advantage plan, check whether it’s an MA-PD (includes drug coverage) or MA-only (does not include drug coverage). If it’s MA-only — which is increasingly rare but still exists — you’d need a separate standalone Part D plan, and you should verify you’re not going without coverage and racking up a late penalty.

💡 Critical Insider Tip: Your red, white, and blue Original Medicare card does not indicate Part D enrollment. That card only confirms Parts A and B. Your Part D coverage is separate and comes with its own member ID card from the private insurer. If you can’t find your plan card, log into Medicare.gov or call 1-800-Medicare immediately to verify.

🏆 10. The Best Medicare Part D Plans for 2026 Aren’t Always the Biggest Names

Choosing a Part D plan based solely on brand recognition is one of the most expensive mistakes seniors make. The “best” plan is entirely dependent on your specific medications, your pharmacy, and your location — not on national advertising budgets.

That said, industry-wide quality ratings and cost analyses do reveal meaningful differences. The best Medicare Part D companies for 2026, according to U.S. News and World Report’s analysis of CMS data, are Centene Corporation and Humana.

Wellcare’s plans have the lowest average premiums and highest quality ratings, while Humana is expanding its $0-premium offerings to 27 states and Washington, D.C. in 2026, with more drug tiers at $0 out-of-pocket costs than many competitors.

2026 Part D Carrier	Average Premium	Star Rating	Strengths	Weaknesses	💡
Wellcare (Centene)	~$8/month	3.4-3.5 ⭐	Lowest premiums, highest quality scores	Prices vary by location	Best budget option 💰
Humana	Varies ($0 available)	3.0-3.2 ⭐	$0 premiums in 27+ states, generous $0 tiers	Member satisfaction dipped; average ratings	Widest $0-premium access 🆓
Anthem (BCBS)	Higher than average	3.5 ⭐	Strong online tools, good enrollment experience	Higher premiums	Tech-savvy seniors 🖥️
UnitedHealthcare (AARP)	Higher than average	2.0-2.5 ⭐	Available in all 50 states + territories	Below-average quality, low satisfaction	Widest availability 🗺️
Aetna (SilverScript)	Mid-range	3.0 ⭐	Good specialty drug coverage	Below-average member experience	Best for specialty meds ⚕️

💡 Critical Insider Tip: UnitedHealthcare/AARP and Blue Cross Blue Shield of several states have the worst-rated Medicare Part D plans in 2026, with ratings of just 2 out of 5 stars from Medicare.gov. Brand recognition doesn’t equal quality. A smaller, lesser-known plan with 4+ star ratings that covers your specific drugs at lower copays will almost always outperform a nationally famous plan with mediocre ratings and higher costs.

🔄 11. 2026 Part D Plans Are Experiencing Their Biggest Transformation in History — Here’s What Changed

The Inflation Reduction Act continues reshaping Part D in 2026, and understanding these changes could save you significant money:

The Part D donut hole was eliminated altogether as of 2025, and that will continue to be the case in 2026. The Inflation Reduction Act also ensures that Medicare Part D enrollees can receive recommended vaccines at no cost, and covered insulin products with copays capped at $35/month.

2026 Change	What It Means	Who Benefits	💡 Action Required
$2,100 out-of-pocket cap	Maximum you pay, then $0 for the rest of the year	Everyone — especially those on expensive medications	Enrollment is automatic — no opt-in needed ✅
10 negotiated drug prices	Lower prices on cancer, diabetes, heart, and blood clot drugs	~9 million enrollees using these medications	Check if your drugs are on the list 📋
Donut hole eliminated	No more coverage gap mid-year	Everyone — eliminates confusing mid-year cost spike	Permanent change — no action needed 🍩❌
$35 insulin cap	Monthly maximum on all covered insulin	Diabetics on insulin — no deductible applies	Applies automatically to Part D covered insulin 💉
$0 vaccines	All ACIP-recommended vaccines at no cost	Everyone — shingles, flu, pneumonia, RSV, etc.	No deductible or copay required 🩹
Prescription Payment Plan auto-renewal	Spreads drug costs into monthly installments	Those who enrolled in 2025	Opt out if you prefer pharmacy payments 📅
15 more drugs for 2027 negotiation	Additional medications being negotiated	Future beneficiaries taking high-cost drugs	Watch for 2027 announcements 🔮

💡 Critical Insider Tip: The maximum Part D deductible increased to $615 in 2026, up from $590 in 2025, but some Part D plans will have lower deductibles or none at all. Don’t assume your plan charges the federal maximum — many competitive plans waive the deductible entirely, especially Wellcare and Humana’s lower-tier plans. Compare carefully during enrollment.

❓ Frequently Asked Questions

Can I have both a standalone Part D plan and a Medicare Advantage plan with drug coverage? No. If your Medicare Advantage plan includes prescription drug coverage (MA-PD), that IS your Part D. You cannot simultaneously hold a standalone PDP. If you switch to Original Medicare during an enrollment period, you’ll then need to add a standalone Part D plan separately.

What happens if my drug isn’t on my plan’s formulary? You have several options: ask your doctor about a covered therapeutic alternative, request a formulary exception (your doctor must provide a supporting medical statement), or if denied, file a formal appeal. Non-formulary prescriptions are not included in the drug list and you pay 100% of the costs out of pocket — and paying for these uncovered medications does not count toward your plan deductible or annual out-of-pocket max.

Does the $2,100 cap include my premiums and deductible? It includes your deductible, copays, and coinsurance for covered Part D drugs. It does not include your monthly premiums, payments for non-covered drugs, or spending on Part B drugs.

Will Medicare Part D cover weight-loss drugs like Ozempic or Wegovy? Currently, Part D only covers GLP-1 drugs when prescribed for conditions other than weight loss (like type 2 diabetes or cardiovascular risk reduction). CMS has proposed expanding coverage to include obesity treatment, and a voluntary model for obesity-specific GLP-1 coverage may launch in 2027. Wegovy is currently covered by less than 1% of Part D plans.

How does the Medicare Prescription Payment Plan work? Instead of paying your full drug costs at the pharmacy, your plan bills you monthly for a smoothed-out share of your anticipated annual drug costs. It doesn’t reduce your total spending — it just makes it more predictable. New for 2026, participation in the plan automatically renews from year to year unless you opt out.

What if I qualify for Extra Help / Low-Income Subsidy (LIS)? Older adults with incomes up to 150% of the federal poverty level qualify for the Medicare Part D Low-Income Subsidy (Extra Help), which lowers premiums and out-of-pocket costs for prescription drugs. If you qualify, you’ll also be exempt from the late enrollment penalty.

Can my Part D plan change its drug list mid-year? Yes, but under strict CMS rules. Plans can add generics to replace brand-name drugs, add biosimilars, or make safety-related changes throughout the year. Your plan’s coinsurance may increase for a particular drug when the manufacturer raises the price, or if you continue to take a brand-name drug after your plan adds a generic or biosimilar alternative.

Sources: Centers for Medicare and Medicaid Services (CMS) 2026 Part D Redesign Program Instructions; CMS 2026 Part D enrollment and eligibility guidance; Medicare.gov drug plan cost and coverage data; Kaiser Family Foundation (KFF) formulary coverage analysis of IRA-negotiated drugs; PAN Foundation Medicare reform guides; U.S. News & World Report 2026 Part D company ratings; NerdWallet and ValuePenguin 2026 Part D plan comparisons; Medicare Interactive drug exclusion guidance; CMS Contract Year 2026 proposed rule on anti-obesity medication coverage; AARP 2026 Medicare Part D changes overview.

Blog