Part D: the plan with the lowest premium is rarely the cheapest
Every Part D plan covers a different list of drugs at different prices through different pharmacies. The only way to pick one is to price your actual prescriptions through each plan for the full year. That's the comparison I run.
Part D is Medicare prescription drug coverage from a standalone plan or built into a Medicare Advantage plan. Every plan has its own drug list and pharmacy network, out-of-pocket costs are capped at $2,100 in 2026, and going 63 days without creditable drug coverage triggers a permanent penalty. The right plan is the one that covers your prescriptions cheapest at your pharmacy, checked every fall.
Two ways to get Part D
- A standalone Part D plan (PDP) — paired with Original Medicare, usually alongside a Medigap policy.
- Built into a Medicare Advantage plan (MA-PD) — most Advantage plans in the Capital Region include drug coverage; you can't add a separate Part D plan on top.
Why "cheapest premium" is a trap
A plan's monthly premium is often a small part of what you actually spend on drugs over a year. The real numbers are set by:
- The formulary — the list of drugs the plan covers. If one of yours isn't on it, you pay full price or go through an exception process.
- Tiers — the same drug can be tier 2 on one plan and tier 4 on another, at three or four times the copay.
- The deductible — some plans charge it on all tiers, some skip it for generics.
- Pharmacy network — "preferred" pharmacies get lower copays; your local pharmacy may or may not be one.
- Restrictions — prior authorization, quantity limits and step therapy on specific drugs.
I enter your exact medications and dosages, and your pharmacy, into a comparison tool and rank plans by total yearly cost. The ordering is very often the opposite of the premium ordering.
What changed recently
Part D has been reshaped over the last few years, mostly in beneficiaries' favour:
- The old coverage gap ("donut hole") is gone.
- There is now an annual cap on out-of-pocket drug costs — $2,100 in 2026, adjusted each year — after which covered drugs cost you nothing for the rest of the year.
- The Medicare Prescription Payment Plan lets you spread out-of-pocket drug costs across the remaining months of the year instead of paying a large amount at the pharmacy in January. Monthly bills can change as you fill prescriptions, and it doesn't reduce what you pay in total.
- Covered insulin is capped at a modest monthly copay, and recommended adult vaccines are free.
The flip side is that some plans have raised premiums or tightened formularies to absorb these changes, which makes the yearly re-check more important, not less.
Plans change on January 1
Formularies, tiers and pharmacy networks are reset every year. A plan that priced your prescriptions perfectly this year can be a poor fit next year with nothing on your side having changed. I re-run every client's drug list during the Annual Enrollment Period.
Help with drug costs for New Yorkers
Two programs stack with Part D:
- Extra Help (the federal Low-Income Subsidy) — lowers premiums, deductibles and copays substantially, and removes the late-enrollment penalty. Applied for through Social Security.
- EPIC — New York's program for residents 65+, with income limits well above Extra Help's. For lower incomes it can pay toward your Part D premium; for everyone it lowers copays once the Part D deductible and any EPIC fee or deductible are met.
If you're anywhere near the limits, read the help-paying page before you choose a plan — qualifying changes which plans make sense.
What I need from you
- Your medication names, strengths and how often you take them (a photo of the labels works).
- The pharmacy you'd like to keep using.
- Your ZIP code and whether you're on Original Medicare or an Advantage plan.
That's enough for a full-year comparison. Send it over or call and I'll come back with the two or three plans worth choosing between.
- Part D late enrollment penalty (medicare.gov) — 1% per month; $38.99 base premium in 2026
- Final CY 2026 Part D redesign instructions (CMS) — $2,100 out-of-pocket cap
- Medicare Prescription Payment Plan (medicare.gov)
- Insulin costs (medicare.gov) — $35 monthly cap
- EPIC program (NY Department of Health)
I do not offer every plan available in your area. Any information I provide is limited to the plans I do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your State Health Insurance Assistance Program for information on all of your options. Not connected with or endorsed by the U.S. government, the Social Security Administration or the federal Medicare program.
Common questions
Short answers to what people ask before they call.
Do I need Part D if I take no medications?
You need Part D or other creditable coverage from the time you're first eligible, or you'll pay a late-enrollment penalty for as long as you have Part D later. The penalty is 1% of the national base premium for every month you went without, permanently. A low-premium plan is the usual hedge.
What counts as creditable coverage?
Drug coverage at least as good as standard Part D — most employer and union plans, VA coverage, TRICARE, and Medicare Advantage plans with drug coverage. Your plan should send you a notice each year saying whether it's creditable. Keep it.
Is there a limit on what I can pay for drugs in a year?
Yes, since 2025. Part D has an annual out-of-pocket cap — $2,100 in 2026, indexed each year. Once you reach it, you pay nothing more for covered drugs for the rest of the year. You can also spread your costs over the remaining months of the year through the Medicare Prescription Payment Plan — it changes the timing, not the total.
Can I change my Part D plan mid-year?
Normally only during the Annual Enrollment Period (Oct 15 – Dec 7), unless you qualify for a Special Enrollment Period — moving, losing other coverage, or getting Extra Help are common ones. People with Extra Help can change plans more often.
What is EPIC?
New York's own program for residents 65 and over: the Elderly Pharmaceutical Insurance Coverage program. It works alongside Part D as secondary coverage — lowering copays after the Part D deductible, and helping with the premium at lower incomes — and the income limits are higher than most people expect. Details on the help-paying page.
Let's talk it through
A phone call or a message is all it takes. The first conversation is just a conversation.