Prescription Drug Plans: What You Need to Know for 2026

Are you experiencing sticker shock when reviewing your Prescription Drug Plan (PDP)
for 2026? I certainly did. My own stand-alone PDP monthly premium increased by
113.9% from 2025 to 2026.

If you’ve been tuning out the slew of commercials about Medicare Open Enrollment and
throwing out the letters and postcards from various Insurers, you’re not alone. Please
endure this important process. Medicare Open Enrollment ends at midnight on
Saturday, December 7, 2025.

For those using HealthCare.gov for coverage under the Affordable Care Act (ACA),
enrollment for plans beginning January 1, 2026, ends on December 15, 2025. While the
states of New York and New Jersey extend deadlines for ACA Marketplace plans to
January 31, 2026, this does not apply to Medicare.

Regardless of where you get your coverage, it is essential to ensure you have a
Prescription Drug Plan that meets your needs. If you take medications and do not have
a PDP, please take the time to sign up for one – either as a stand-alone plan or as part
of a Medicare Advantage plan. Delaying enrollment can result in a late-enrollment
penalty.

What to Consider When Choosing a PDP

1. Medication Coverage

• Are your prescriptions included on the list of drugs that the Insurer’s plan covers?
• What are the coverage limitations or requirements?

Costs/Out-of-Pocket Expenses

• Stage 1: Deductible – You pay the full cost of your medication until you meet the plan’s
  deductible.
• Stage 2: Initial Coverage – After meeting the deductible, you pay copays or
  coinsurance until you reach the plan’s out-of-pocket limit.
• Stage 3: Catastrophic Coverage/Out-of-Pocket Maximum – The Inflation Reduction
  Act’s full annual out-of-pocket cap for Medicare Part D began on January 1, 2025. As of
  that date, once a beneficiary’s total Part D cost-sharing reaches the $2,000.00 cap, they
  owe no additional cost-sharing for covered Part D drugs for the rest of the year. The
  $2,000 cap applies to true out-of-pocket spending. In 2026,the cap will be adjusted for
  inflation; the Centers for Medicare & Medicaid Services will publish the updated amount.

Drug Tiers (varies by plan)

• Tier 1: Preferred generics
• Tier 2: Generics
• Tier 3: Preferred brands
• Tier 4: Non-preferred medications
• Tier 5: Specialty drugs

Pharmacy Choice

• Is your preferred pharmacy in-network?
• Are mail-order options available, such as the delivery service that is provided by
  Express Scripts?

Plan Type

• HMO: Lower premiums, many such plans require referrals from your Primary Care
  Physician to specialists, limited network of providers
• PPO: More flexibility, higher premiums, out-of-network coverage

Yesterday, I spent a few hours online and on the phone comparing my options and
ultimately enrolled in a new PDP. It’s a process, but there are people who can help.

Helpful Resources
NY State of Health (New York State Marketplace): Official state-level marketplace for
uninsured or underinsured New Yorkers.

• Phone Nos.:1-855-355-5777; TTY 1-800-662-1220
• nystateofhealth.ny.gov
  Healthcare.gov (ACA/Federal Marketplace): Use this if you live in a state without its
  own marketplace or are comparing federal ACA plans.
• Phone Nos.: 1-800-318-2596; TTY: 1-855-889-4325
• HealthCare.gov
  Medicare (Federal Medicare program): Primary source for Original Medicare – Parts
  A, B, and D.
• Phone Nos.:1-800-MEDICARE (1-800-633-4227) TTY: 1-877-486-2048
• Medicare.gov
  AARP: Medicare Plans endorsed by AARP and provided by United Healthcare
• Phone Nos: 1-800-905-6061 (TTY 711)
• aarpmedicareplans.com

E-Health: Online health insurance marketplace. Useful for comparing private and
Medicare-related plans, including PDPs.

• Phone No.: 844-298-9085
• ehealthinsurance.com
  
  SHIP (State Health Insurance Assistance Program): Free, unbiased help available in
  every state.
• shiphelp.org (national directory