This week, we’re well into Medicare open enrollment, which continues for the next month or so. While much of the focus is on health coverage – specifically Medigap and Medicare Advantage plans – there’s another vitally important piece of the insurance coverage puzzle that should not be overlooked: your prescription drug plan, referred to in Medicare shorthand as Part D.
If you’re on a Medicare Advantage plan (the choice, for better or worse, of about half of all Medicare beneficiaries), odds are your prescription coverage is part of your policy. Other Medicare recipients must deal with the shifting landscape of stand-alone drug plans. But regardless of which type of plan you have, important details may change in 2026: which medications are covered, at what out-of-pocket cost, and which pharmacies have either been added to or dropped from your plan. You need to do your homework.
This week we’re bringing you this article from the New York Times in which reporter Mark Miller spotlights some of the reasons why, as one expert put it, this is not the year to sleep through open enrollment. If you ignore this window of opportunity, which lasts through December 7th, you could be in for a costly surprise come January. (Please note that a subscription may be required to access the New York Times article.)
Last Year’s Bargain Plan Now Costs a Whole Lot More
Miller begins his article by introducing us to Holly Kluck, a retired teacher in New Jersey, who “found a great price on a prescription drug plan when she signed up for Medicare last year — a premium of just $18 a month.”
But for Kluck—like for so many—the bargain wouldn’t last. She recently learned that her premium would jump more than $50 next year, Miller tells us. The rate hike is puzzling, since she doesn’t take any medications. “The costs for her husband, Jeff, would rise by a similar amount,” Miller adds.
Along with other increases, the Klucks estimate that their annual Medicare premium costs might have risen by a whopping $2,000 by 2026. This has led them to shop for new Part D prescription plans during the current annual enrollment period, which will end December 7th.
Holly believes she may have some lower-cost options, but Jeff’s are more restricted; he needs an expensive blood thinner. The sentiment expressed by Holly Kluck is the same expressed by so many during this enrollment season: “It’s so complicated, isn’t it?”
Price Changes Vary Widely as Part D Costs Fluctuate
Miller writes, “The Klucks’ experience is an important reminder: Check your Medicare prescription drug coverage during fall enrollment. That’s especially true this year, as price changes will vary widely.”
There are some exceptions, he says. If you are enrolled in traditional Medicare Part A (which covers hospitalizations) and Part B (which covers outpatient visits) and you have a supplemental Medigap policy, Miller says there’s little need to review that coverage.
“But,” he writes, “the Part D insurance market is adjusting to stronger prescription drug coverage under the Inflation Reduction Act of 2022, which imposed a cap on patients’ out-of-pocket spending (like co-payments and deductibles) for covered drugs — it will be $2,100 in 2026. The cap has helped protect beneficiaries who take pricey drugs for conditions like cancer and multiple sclerosis.”
Trump Administration Adjusts Controls on Price Hikes
These changes have a bit of a political history to them, Miller tells us. The Biden administration—in an effort to curb higher premiums as a consequence of shifting risk to insurance companies—granted subsidies to drug plans that agreed to participate in a special program. In return, plans limited monthly premium increases to $35.
Miller writes, “That ‘premium stabilization’ program will continue in 2026, but the Trump administration reduced the subsidies. In 2026, participating insurers may raise premiums as much as $50 per month; some, like Ms. Kluck’s, did not participate and will enact larger increases.”
Health care research nonprofit KFF found that only a few national drug plans were raising premiums substantially this year, Miller tells us. Four will charge less in 30 or more states, and two (offered by Humana) have reduced premiums in nearly every state, according to KFF. But KFF did find that the monthly premium for Wellcare Value Script—the most popular plan nationally—will increase in 32 states and the District of Columbia.
You Might Find Part D Coverage with a Zero Premium
Location is a key factor that determines your coverage options, Miller says. Depending on which state you live in, you may have access to as many as six plans that have zero premium.
“These plans are not offered in all states, but their numbers are growing,” Miller writes. “Such plans typically come with the highest allowable deductible — $615 in 2026, up from $590 this year – but they can be a good option if you use only a few generic medications.”
But Juliette Cubanski, deputy director of the program on Medicare policy at KFF, has a warning for those who take costlier name-brand drugs: look carefully before you pick a plan. “You could end up paying much more overall if coverage for the drugs you take is limited,” Dr. Cubanski says.
Zero-Premium Plans May Come with Future Surprises
If you choose a zero-premium plan, says Kylie Stengel—principal at research and consulting company Avalere Health—then watch out for higher premiums in subsequent years. “They’re trying to attract a healthier beneficiary population so they can actually price the product lower,” she says.
Having a wide view is vital, says Dr. Cubanski, who urges beneficiaries to look beyond the monthly premiums when shopping. Consider whether your drugs are covered, look for any restrictions on those drugs, and explore the deductibles and other out-of-pocket costs.
“People tend to focus only on the premium when they are shopping, perhaps to their detriment,” she says.
MA Enrollees Also Need to Check Their Drug Coverage
Miller warns that Medicare Advantage enrollees should also be on the lookout for changes to their drug coverage, or even the list of in-network providers.
“During fall enrollment, you can switch Advantage providers or shift to traditional Medicare — but don’t do that without confirming that you will be able to buy Medigap supplemental coverage,” he explains. “Those who apply for Medigap after [the initial 6-month guaranteed enrollment period] can be rejected for pre-existing conditions in most states.”
He adds, “If you’re in an Advantage plan this year, or considering shifting to one for 2026, start by examining drug coverage, just as you would in a stand-alone Part D plan. Be sure to evaluate whether your drugs are covered, whether you’ll pay a premium and any deductible for drugs. Then make sure the doctors and hospitals you prefer are in your plan for next year.”
Medicare Plan Finder Lists MA Providers, but Inaccuracies Persist
Philip Moeller, an expert on Medicare and publisher of the Substack newsletter Aging in America, warns that while the government-run Medicare Plan Finder tool is adding directories of providers to its Medicare Advantage listings this year, it is a work in progress and listings may contain errors. He suggests checking with your doctors about the plans you’re considering.
“I’d just call and ask which plans they are participating in next year, and whether the hospitals where they have privileges are included in those networks,” he says.
Medicare regulations say that, if you do choose a plan based on incorrect information, you’re not locked in initially. You may switch plans during the first three months of the new year.
“There’s also an ongoing Advantage Open Enrollment Period during the same months that permits you to switch plans,” Miller writes. “Most enrollees can choose from 30 or more Advantage plans, KFF reports. But the options are very limited in some parts of the country. Four states have fewer than five.”
Some Important Shopping Tips for Prescription Drug Plans
Miller includes the following list of tips to help you navigate the plan-shopping process:
Review your annual notice. As we recently covered here on the Blog, your plan provider must send you an Annual Notice of Change letter (or ANOC) every fall, either by snail-mail or email. You should have received it by September 30th. “This will include the premium and the annual deductible,” Miller explains. “It will also tell you if coverage of your drugs will change or if changes are being made to your Medicare Advantage providers.”
Use the finder. “The Medicare Plan Finder allows you to compare stand-alone drug and Advantage plans,” Miller writes. “Check your profile to make sure your list of medications is current. You’ll see premiums and total projected annual costs, including deductibles and out-of-pocket costs.”
Watch the tiers. In any given plan, drugs are typically grouped into tiers; lower-cost drugs like generics are in the lowest tiers. “The change notice will show if a drug has moved from the first to the second or third tier; if that happens, you may face higher out-of-pocket costs or hassles getting a medicine covered,” Miller writes.
Consult the stars — carefully. Medicare Plan Finder will include “star” ratings beside MA and stand-alone drugs plans. Miller explains, “The rating program is used to determine ‘bonus’ payments to plans for quality improvements, and to help consumers make informed decisions.” (You’ll find a related article on the star rating system this week on the Blog.)
But the ratings may not reflect your likely experience. Laura Skopec—research associate at the Urban Institute—urges caution, since star ratings reflect how numerous regional plans, grouped under one Medicare contract, perform. “Overall, the ratings don’t tell beneficiaries much about the experience they’re likely to have in their local plan,” she says.
Contact the SHIP. Miller writes, “Each state has a State Health Insurance Assistance Program, which offers comprehensive, unbiased guidance on plan selection.” We should add that the program in Washington State, home to AgingOptions and Life Point Law, is called SHIBA – Washington’s Statewide Health Insurance Benefits Advisors.
Use caution with brokers. Laura Skopec says that independent insurance brokers “live and die on referrals, so they really are trying to do the best they can for their clients.” But she adds that brokers don’t represent every plan available, especially more niche regional offerings, and they are often incentivized by higher commissions to favor Advantage plans rather separate Part D and Medigap policies.
Seek Extra Help, a program for low-income seniors. Miller concludes, “Beneficiaries with low incomes and modest assets are eligible for assistance with Part D out-of-pocket costs. Assistance paying for Part B premiums is available through the Medicare Savings Programs.”
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(originally reported at www.nytimes.com)