Part D
Prescription cover is priced on your list, not the brochure
Two neighbours can pick the same plan and have a five-hundred-dollar difference in their year, purely because of which tier their medicines land on. This page shows you where to look.
- 2026 sample figures
- Penalty formula shown
- Drug list priced free
How you pay
Three stages, and a cap at the end
Part D used to have four stages and a gap in the middle that nobody could explain. It now has three, and the third one is good news.
Deductible
If your plan has one, you pay the full negotiated price until you meet it. The law caps the Part D deductible at $615 for 2026 — a sample figure — and many plans set theirs lower, or apply it only to the higher tiers.
Initial coverage
You pay the copay or coinsurance printed against each tier and the plan pays the rest. Most people spend the whole year here and never think about the stages at all.
The annual cap
Once your own out-of-pocket drug spending reaches $2,100 for 2026 — again a sample figure — you pay nothing more for covered drugs for the rest of the year. This cap replaced the old doughnut hole, and it is the biggest change to Part D in a generation.
An estimate for planning, not a quote. Medicare and the Marketplace set your real figures.
Formulary
Tiers decide what you pay
A formulary is the plan's list of covered drugs, sorted into tiers. Find your medicines on it before you find the premium.
| Tier | Usually holds | What you pay |
|---|---|---|
| Tier 1 | Preferred generic | Lowest copay, often a flat few dollars at a preferred pharmacy. |
| Tier 2 | Generic | Still a copay, slightly higher. |
| Tier 3 | Preferred brand | Copay or coinsurance. Where most brand-name maintenance drugs sit. |
| Tier 4 | Non-preferred drug | Usually coinsurance — a percentage, so the price of the drug matters. |
| Tier 5 | Speciality | Coinsurance on high-cost drugs. Exceptions requests rarely move a drug off this tier. |
| Tier 6 | Select care | Not every plan has one. Low-cost drugs for chronic conditions, sometimes $0. |
Shopping
Six checks before you enrol
Start with your list
Every drug, the exact dose, and how often you fill it. A plan is only cheap if it is cheap for your particular list — there is no such thing as a generally good Part D plan.
Check the tier, not the price
The same medicine can sit on tier 2 in one plan and tier 4 in another. Tier decides whether you pay a flat copay or a percentage, and percentages on expensive drugs are where budgets break.
Check your pharmacy
Plans have preferred and standard pharmacies, and the difference at the counter is real. A plan that is excellent at a chain two towns over may be mediocre at the shop you walk to.
Check restrictions
Prior authorisation, step therapy and quantity limits apply to particular drugs. Finding one attached to your maintenance medicine in January is a bad way to start a year.
Read the ANOC
The Annual Notice of Change arrives each September and lists exactly what is moving. Formularies change every 1 January; loyalty to last year's plan is not rewarded.
Ask about Extra Help
The low-income subsidy can wipe out most drug costs for people who qualify, and plenty of people who qualify never apply because nobody suggested it.
The penalty
1% a month, for as long as you have Part D
The late-enrolment penalty is the number of full months you went without creditable drug cover, multiplied by 1% of the national base beneficiary premium, rounded to the nearest 10 cents.
| Months uncovered | Formula | Added to your premium |
|---|---|---|
| 12 months without cover | 12% × $36.78 | ≈ $4.70 a month |
| 24 months without cover | 24% × $36.78 | ≈ $9.40 a month |
| 36 months without cover | 36% × $36.78 | ≈ $14.00 a month |
| 60 months without cover | 60% × $36.78 | ≈ $23.40 a month |
- People who qualify for Extra Help do not pay the Part D late-enrolment penalty.
- Keep every creditable-coverage letter an employer sends you. It is the evidence that cancels a penalty notice.
Part D
Prescription questions
Almost always, yes. Without creditable drug cover the late-enrolment penalty accrues 1% a month and then follows your premium for as long as you have Part D. A minimal plan now costs less than the penalty later, and it means you are covered the first time a doctor writes something expensive.
Drug cover that is expected to pay, on average, at least as much as standard Part D. Most employer and union plans qualify and must tell you so in writing each autumn. Keep that letter — it is what stops a penalty being applied later.
The coverage gap as people knew it is gone. Part D now runs deductible, initial coverage, then a hard annual cap on your own out-of-pocket drug spending — $2,100 for 2026, a sample figure that moves each year. There is also an option to spread those payments across the months of the year rather than paying them as they fall.
Drugs administered to you in a clinical setting — infusions, injections given by a professional, some nebuliser medicines and immunosuppressants after a covered transplant — generally fall under Part B. The same molecule can be a Part B claim in an infusion suite and a Part D claim at the pharmacy counter.
Usually only at the Annual Enrolment Period, 15 October to 7 December, unless you have a Special Enrolment Period — a move, a change in Medicaid or Extra Help status, or a plan leaving your county. People with Extra Help generally get additional chances during the year.
Send your medication list. We will price it against every plan we offer.
Names and doses, that is all. You get back a comparison of annual cost at your own pharmacy, and we tell you which restrictions would apply.
- Your list, your pharmacy
- Annual cost, not premium
- No cost to you
Get a free plan review
A licensed, local advisor — usually the same day.
(912) 555-0148Mon – Thu 8:30 am – 6:00 pm