When someone asks me to help them look at Medicare prescription drug coverage, one of the first things I want to see isn’t an insurance plan. It’s their medication list.
That’s because two people living in the same area can have very different prescription needs. A Part D plan that works well for your neighbor, spouse, or friend may not align with your own medications and pharmacy preferences.
So when I help someone compare the Medicare Part D prescription drug plans I’m contracted and authorized to offer, I start with their actual situation.
First, Let’s Look at What You Take
Before comparing plans, I want an accurate list of your current prescriptions.
- The medication name
- Dosage
- How often you take it
- Quantity
- Whether you’re taking the brand-name or generic version
Medicare drug plans have their own lists of covered drugs, called formularies. A medication may be covered differently from one plan to another, so simply comparing monthly premiums doesn’t tell you the whole story.
Is Your Medication on the Formulary?
Medicare advises people with drug coverage to check their plan’s drug list, or formulary, to determine which outpatient prescription drugs the plan covers. But I want to look further than simply asking whether a medication is covered.
- What tier is the medication on?
- What are the applicable copayments or coinsurance?
- Is prior authorization required?
- Does step therapy apply?
- Are there quantity limits?
These details can affect how your coverage works and what your estimated prescription costs may be.
Then We Look at Your Pharmacy
When comparing Medicare Part D prescription drug plans, your pharmacy matters too. Depending on the plan, using one participating pharmacy rather than another may affect your prescription costs. If you’ve used the same local pharmacy for years and want to continue using it, tell me. If you’re comfortable considering another pharmacy or mail-order options where available, that’s useful to know as well.
Don’t Choose Medicare Part D Prescription Drug Plans Based Only on the Premium
The monthly premium is important, but it isn’t the only potential cost.
- Deductibles
- Copayments
- Coinsurance
- Prescription costs
- Pharmacy network
- Formulary placement
- Coverage requirements
That’s why I prefer looking at your estimated overall prescription costs and coverage needs, rather than focusing on a premium by itself.
There’s an Important Part D Change for 2026
For 2026, the annual out-of-pocket threshold for covered Part D drugs is $2,100. Once your applicable out-of-pocket spending on covered Part D drugs reaches that threshold, you enter catastrophic coverage for the remainder of the year.
This is one of the reasons it’s important to use current Medicare information rather than relying on something you read about Part D several years ago.
What About the “Donut Hole”?
You may have heard people talk about the Medicare Part D “donut hole” for years. The Part D benefit structure has changed, and the coverage gap phase commonly referred to as the ‘donut hole’ was eliminated beginning in 2025. For 2026, I focus on the current Part D benefit structure, your medications, pharmacy preferences, plan requirements and estimated costs.
Why Your Medicare Part D Prescription Drug Plans Should Be Reviewed Every Year
Even if you’re happy with your current coverage, I recommend reviewing it for the coming year because both plans and personal circumstances can change.
- A plan’s formulary may change
- Pharmacy arrangements may change
- Premiums may change
- Cost-sharing may change
- Benefits may change
- You may start or stop a medication
- Your dosage may change
- You may change pharmacies or move
That’s why I make annual Medicare coverage reviews available to my clients. I’m not assuming that changing plans is necessary. The point is to review rather than assume.
Prescription Coverage Is Only One Part of Your Medicare Picture
- Your doctors
- Specialists
- Hospitals
- Pharmacies
- Healthcare needs
- Budget
- Travel considerations
- Provider networks based on currently available directories
- Additional benefits where available
Medicare is personal. Your medications and healthcare providers may look completely different from someone else’s, which is why I believe the comparison should start with you. If you’re also weighing Medicare Advantage vs. Medicare Supplement, that decision affects how your drug coverage fits together, since Medicare Advantage plans often bundle Part D coverage while Medicare Supplement plans do not.
Need Help Reviewing Your Prescription Drug Coverage?
If you’d like help understanding your Medicare Part D prescription drug plans, I can help you review the Medicare options to offer based on your individual circumstances. Contact me, and bring your medication list, your preferred pharmacy information, and any questions you have. We’ll start there.
There is no additional fee for my Medicare plan guidance. If you enroll through me, I may receive compensation from the insurance carrier.
Disclosure
We do not offer every plan available in your area. Any information we provide is limited to the plans we offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to obtain information on all of your options.
Plan availability, formularies, pharmacy networks, premiums, costs, and benefits vary and may change from year to year.
