Some considerations when picking your Medicare Standalone Part D plan for 2026

[GailL1]

When looking over a plan, make sure to note how your part of the coverage is described:  Big difference when it says “co-insurance” instead of  “co-pay” .

That seems to be another place where some of the changes are taking place.

Also, remember there is the installment payment option for those on really expensive meds - a way to soften the blow even with the $ 2100 deductible for 2026.  The installment payment option for Medicare Part D is called the Medicare Prescription Payment Plan (MPPP). This voluntary program, available starting in 2025, allows eligible Medicare Part D enrollees to spread their out-of-pocket prescription drug costs across the calendar year instead of paying the full amount at the pharmacy. You must opt into the plan by contacting your Part D plan sponsor and setting it up with them.  

Medicare.gov - What is the Medicare Prescription Payment Plan? 

It does help in managing your [high] drug cost and there is no charge for this benefit.

[Winter2025VA]

[9/28/25] Gail @GailL1 , thanks for this info.

On 9/20/25 I received my WELLCARE Annual Notice of Change for 2026 in the mail.

Looks like my plan will exist in 2026 that I have NOW in 2025.

Still zero premium costs but looks like my two meds will be $5 each, versus $0 this year 2025.

On October 1st, I will call my local LOA to set up my usual Medicare Overview appt.

I have the Standalone Part D & Traditional Medicare.

Take care,

Nicole!

[CBtoo]

Ask your doctors if there are any other drugs you need to check in the formulary (what drugs they cover and at what tier). I did that and found out that if I continue to have side effects the one drug I am on they were going to try X next. Wellcare (what I currently have) does not have that on any of their formulates with any of their plans and the manufacturer does not help those with Medicare (it is a $900ish a month drug). 

WARNING TO ALL READING THIS THERAD - Be SURE to check your D this year as there are a number of companies making major changes (likely will cost you more) so it is worth entering all your drugs and pharmacies and see which D is cheapest in the long run for you next year.

There are some that are dropping out of the D business. If yours is one of them and you missed reading that piece of mail (or online notice if you have opted for online notifications) you will have some real problems if you fail to sign up for another D. 

[Winter2025VA]

[9/29/25] Carolyn @CBtoo , how long have you had WELLCARE? So good hearing from you my friend. Nicole. 💛

➡️[*** CAROLYN 

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@CBtoo wrote:

Ask your doctors if there are any other drugs you need to check in the formulary (what drugs they cover and at what tier). I did that and found out that if I continue to have side effects the one drug I am on they were going to try X next. Wellcare (what I currently have) does not have that on any of their formulates with any of their plans and the manufacturer does not help those with Medicare (it is a $900ish a month drug). 

WARNING TO ALL READING THIS THERAD - Be SURE to check your D this year as there are a number of companies making major changes (likely will cost you more) so it is worth entering all your drugs and pharmacies and see which D is cheapest in the long run for you next year.

There are some that are dropping out of the D business. If yours is one of them and you missed reading that piece of mail (or online notice if you have opted for online notifications) you will have some real problems if you fail to sign up for another D. 

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[CBtoo]

I've only had Wellcare this year. I have had something like 4 or 5 plans in 6 years. Checking each year saves me a fair bit of money. 

With medicare D my big issue is if you don't have ESP to know an expensive drug you will be prescribed later in the year. I have been "burned" twice by this so far. One time on the formulary but really expensive and this time not on the formulary and incredibly expensive. Expensive enough I am not taking it despite it being the best choice.

[GailL1]

@CBtoo 

In case that happens - being prescribed a new expensive med later in the year - you know what to do - right?    You with the help of your doctor file an exception with your Part D insurer - 

CMS.gov - EXCEPTION 

from the link ~

An exception request is a type of coverage determination.  An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.

• A tiering exception should be requested to obtain a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.
• A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug.

Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee.  Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.

more information at the link ~

[CBtoo]

Of course we appealed. They denied saying there were plenty of other drug and I needed to try them first (already had with some of them, had dangerous side effects to that entire family of drugs, some listed were inappropriate, so I guess they didn't read that part of the appeal). As the person appealing works in the number one department in the country for that problem likely they know exactly what I need. I'd suspect a bot (aka AI) or an RN made the decision.

So we appealed the denial. And lost again. Now it has been 4 months plus. Fortunately the place did the clinical trial for that drug and now they are trying to get it another way for me. I have an appointment about that in 2.5 weeks.

When I checked D on medicare.gov only 5 or 6 D's had it on the formulary and the cheapest had premiums of $98/mo, my Wellcare zero dollar drugs were $39-$59/mo (old, cheap generics - so clearly the companies are getting money out of people like me to pay for the folks who would have hit the donut hole when there was one). I'd hit the entire $2000 out of pocket the hard way. No "extra credit" for the difference between the the list price and what the company is calling the price credited to the out of pocket (I know someone on one of those new weight loss drugs who only paid $67 for drugs the entire year because of that).

So there are the "rules" and then there are how they implement them. There needs to be more than prior authorization denial reform with Advantage plans - need it for drug denials too.

[GailL1]

@Winter2025VA 

Sounds like the plan is still a good value - I just wanted people to make sure they were reading their plans carefully and that a “co-insurance” % wasn’t replacing what was once a co-pay.  Most of the time this is involving the higher tier med - maybe tier 3 and above.  

[CBtoo]

Many D's are switching to percent of drug cost rather than flat fee for drugs. And from what I have been reading on the insurance forum more plans have premiums that are much higher (although apparently Wellcare still has zero dollar/low dollar premium plans). In addition what drug is on what tier is changing more than it has in the past and some formularies are smaller than they were with some of the expensive drugs kicked off. Also the copay for some of the expensive drugs is going up. 

I think next year it is going to cost many of us far more money for our same drugs. 

[CBtoo]

I have read on an insurance forum that more and more companies are dropping zero dollars as the price for cheap generics and, as the person above said, charging for them now. Grant you $5 isn't a huge amount but that is still a budget issue for some people.

[GailL1]

It is what it is - drug plan insurers and the manufacturers had to start picking up more of the cost when the Inflation Reduction Act changed the price structure of Part D plans and the total amount out of pocket cost for the beneficiary was put into plan ce in 2025.  

Last year, the government to help cushion the blow of insurers having to pay more, offered a stabilization amount which helped last year.  It is still in place for those insurers that took advantage of it in 2025 but the amount of the stabilization dropped in amount.  Next year, it maybe no more.

The cost of the GLP-1 drugs is one of the biggest factors this year and that is even with Medicare not covering them on the formularies if the reason is only for weight loss - more diseases are being added to their use but who know they may decide to cover them just for weight loss somewhere down the line.  

Yes, there are fewer zero premium plans - depends on the area - Yes, many plan show the upper tier drug prices as a % of cost for the coinsurance rather than co-pays.  Folks just need to read the plans closely.  

Edited to add:  The deductible is also higher and will get higher too - $615 for 2026.  It is all a need and mathematical call - some people may be much better off signing up for an enhanced plan without a deductible and having higher premiums.  Everybody just has to figure it out based on their needs and their pocketbooks - same way with any other insurance of whatever type.

Not many people last year took advantage of the installment drug payment plans from the insurers - this is continuing this year - known as the MPPP (Medicare Prescription Payment Plan) - so if somebody needs this, they should contact their insurer cause they have to set up the plan with the pharmacy.  

Change is the only thing that is a constant - we have to adjust based on change.  I am glad that we have a PDP - aren’t you?