Medicare Part D 2026
Prescription drugs can become one of the most expensive parts of your health coverage if you don’t plan for them accordingly. The first part of preparing for anything is understanding how it works. This article, “Medicare Part D 2026,” will help you know all the parts you need to understand. Take your time, it’s not a long article, but it’s important. If you find anything confusing at any point, please know that you are not alone. We are here to help you if you need us.
I intend to answer most of your questions in this article, but if I miss something, please email me at support@myphss.com, and I will answer your question.
What is Medicare Part D?
Medicare Part D is the federal prescription drug benefit introduced in 2006 to help people with Medicare cover the costs of self-administered medications. It’s available through private insurance companies that Medicare approves. These plans help pay for your drug costs, but you still might have to pay out-of-pocket costs through premiums, deductibles, copays, and coinsurance.
Who Qualifies for Medicare Part D?
Medicare Part D is available to anyone who is eligible for Medicare, regardless of income, health status, or current prescription needs.
To qualify for a Part D prescription drug plan, you must:
✅ Be enrolled in Medicare Part A and/or Part B
You can sign up for a standalone Medicare Part D plan if you have either Part A or Part B, or both. You don’t need both to qualify—just one is enough.
✅ Live in the plan’s service area
You must reside in the service area of the Medicare drug plan you wish to join. Each plan is available only in certain counties or states, so it’s important to choose one that covers your ZIP code.
✅ Be a U.S. citizen or lawful resident
You need to be a U.S. citizen or a legal resident who has lived in the U.S. for at least five continuous years.
⚠️ You cannot have duplicate coverage
If you’re already enrolled in a Medicare Advantage Plan (Part C) that includes prescription drug coverage, you cannot also enroll in a standalone Part D plan. If you try to do both, Medicare will automatically cancel your Advantage plan and move you back to Original Medicare.
🌟 Special Note for People Under 65
Some individuals under age 65 also qualify for Medicare Part D if they are:
Receiving Social Security Disability Insurance (SSDI) for 24 months
Diagnosed with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS)
If they qualify for Medicare, they also qualify for Part D.
💡 What If I Have Employer or VA Drug Coverage?
If you already have creditable drug coverage through an employer, union, VA, or other source, you may choose not to enroll in Part D immediately. Just make sure your existing coverage is considered creditable (as good as or better than Medicare’s standard), or else you may face a late enrollment penalty later on if you decide to sign up
📅 When Can I Sign Up for Medicare Part D?
1. Initial Enrollment Period (IEP)
Your first chance to join is the 7-month window surrounding your 65th birthday—starting 3 months before, the birthday month, and 3 months after.
Failing to enroll here may result in a lifetime penalty—a monthly premium increase of about 1% of the national base premium for each uncovered month.
2. Annual Enrollment Period (AEP)
Each year, from October 15 to December 7, you can enroll in, switch, or drop a Part D plan. Coverage for changes takes effect January 1 of the following year
3. Medicare Advantage Open Enrollment
From January 1 to March 31, if you’re in a Medicare Advantage plan (Part C), you can drop it and switch to Original Medicare plus a standalone Part D plan.
4. Special Enrollment Periods (SEPs)
Life changes—like moving, losing other drug coverage, or entering a long-term care facility—can qualify you for a SEP to join or switch plans mid‑year.
🛠️ How Does Medicare Part D Work?
Medicare Part D helps you pay for prescription medications. But it’s not run directly by Medicare—it’s offered by private insurance companies that are approved by Medicare. Each plan is a little different, but they all follow the same basic structure.
Let’s walk through how it works, step by step.
You Choose a Drug Plan That Fits Your Needs
You have the option to:
Enroll in a standalone Part D plan if you have Original Medicare (Part A and/or Part B)
OREnroll in a Medicare Advantage plan (Part C) that includes built-in drug coverage
You’ll want to compare plans based on the medications you take, the pharmacy you prefer, and your budget. Not all plans cover the same drugs or charge the same copays.
Each Plan Has a Drug List (Formulary)
Every plan has a formulary, which is a list of the medications it covers. Drugs are grouped into tiers, and each tier has a different cost:
Tier 1: Low-cost generic drugs
Tier 2: Preferred brand-name drugs
Tier 3: Non-preferred brand-name drugs
Tier 4/5: Specialty medications
Tip: Before joining a plan, make sure it covers the medications you take—and check which tier they fall into to know what your copay will be.
You Pay Monthly and Out-of-Pocket Costs
Medicare Part D plans usually have:
Monthly premium – The amount you pay to have the plan (varies by plan)
Annual deductible – The amount you must pay out of pocket before the plan begins paying (in 2025, this can be up to $545)
Copayments/coinsurance – Your share of the cost for each prescription after you meet your deductible
If your income is higher, you may also have to pay an additional IRMAA surcharge (Income-Related Monthly Adjustment Amount).
🆘 5. Extra Help Is Available for Low-Income Seniors
If you’re living on a limited income, you might qualify for a program called Extra Help (also known as the Low-Income Subsidy). This helps reduce your monthly premium, annual deductible, and the cost of your prescriptions.
💡 MyPHSS can help you check if you qualify and assist with the application.
6. Use a Network Pharmacy
Most Part D plans have a preferred pharmacy network, and you’ll save money by filling prescriptions at one of these locations. Always check whether your pharmacy is in-network before filling a prescription.
🔁 7. You Can Switch Plans Every Year
Drug plans change every year. New medications may be added (or removed), costs can go up or down, and pharmacies can change.
That’s why the Annual Enrollment Period (October 15 – December 7) is so important—it gives you the chance to review your plan and switch if needed.
💡 Even if your plan worked great last year, it’s smart to check your options each fall.
If you’re unsure which Medicare Part D plan is right for you—or want help comparing options based on your prescriptions—MyPHSS is here to help.
📞 Call us today at 813-328-4664, email support@myphss.com, or visit www.MyPHSS.com to schedule a no-cost appointment with one of our licensed agents.
I intended to answer most of your questions in this article, but if I missed something, please email me at support@myphss.com, and I will answer your question.
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