Another LONG newsletter devoted almost 100% to Part D 2026. Feel free to pass along to your friends.

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DMajor Changes in the PDP Market for 2026

Fewer plans this year . . . 10 vs 14 in 2025 . . . from 30 to 10 in 6 years

https://www.kff.org/medicare/the-uncertain-future-of-medicares-stand-alone-prescription-drug-plan-market-and-why-it-matters/

Higher premiums, higher deductibles, higher copays . . .

2026 PDP GRID (CLICK LINK) - GEORGIA PDP SUMMARY

https://docs.google.com/document/d/1qxvednqE4livSuQEuSiZyS4IiGuzzQdiUBKdk8eeiDs/edit?usp=sharing

Why Now???

For 2026, Part D Medicare prescription drug plans will include a higher out-of-pocket maximum of $2,100 and a higher deductible of $615.

 Key changes from the 2022  Inflation Reduction Act (IRA) that take effect in 

2026. (This is typical for Congress. They write a law and pass it to become effective in the future, hoping they will not be blamed for the mess THEY created).

Capped Insulin Costs: For a one-month supply of covered insulin, the cost-sharing amount for Part D enrollees will be capped at the lesser of $35 or 25% of the negotiated price.  (Note, your insulin MUST be included on your plan FORMULARY to quality for this copay)

Due to the scaled-back (taxpayer funded) subsidy program, some beneficiaries may experience sharper premium increases for their Part D plans in 2026. 

Forced voicemail and diagnosis codes are endangering patient access to medications - CVS Pharmacy

I won’t be using CVS pharmacies anymore. Sure, I may still need to send prescriptions their way as a physician—but as a consumer, I’m done.

Why?

CVS has recently implemented a new phone system that forces callers to leave a voicemail instead of waiting on hold. The idea is to streamline operations, letting pharmacy staff return calls when they have time. It’s supposed to manage call volume, reduce wait times, and shield staff from verbal abuse during peak hours. On paper, it sounds efficient. In practice, it’s alienating and frustrating.

Voicemail system: When you call to speak to a pharmacist or tech, you’re routed to voicemail. No human option. No option to wait.

Call backs: Staff return your message when they can—maybe within an hour, as promised, maybe not.

Justification: CVS claims this improves workflow and customer experience.

https://kevinmd.com/2025/07/forced-voicemail-and-diagnosis-codes-are-endangering-patient-access-to-medications.html

SELF ENROLL RENEWAL

Several factors have created a perfect storm for the PDP (prescription drug plan) market for 2026

Carrier animosity (reduced government funding = cost shifting)

Medicare Part D enrollment process (no way to track applications)

E&O (no coverage if the agent is not appointed to represent the carrier)

I am just the messenger in this mess. Many of the problems created by others in the food chain blow back on me . . . and I will no longer be the scapegoat.

PDP pricing (premiums, copays and underlying Rx costs) are not predictable from year to year and I often have to field the WHY questions. Increases are the result of changes in government funding (for drug plans AND manufacturers) plus market forces . . . supply chain, tariffs, de minimis rule changes, etc.

For several years I have helped clients find and enroll in drug plans. I have never been paid for the advice or submitting the application with Medicare. This was my choice in order to provide the most comprehensive information and assistance to my clients. The PDP compensation structure was nominal but the hassle factor of complying with certification, licensing and operating within the boundaries of what I could tell a client was not worth it to me. I have been working on a gratis basis to better serve you.

Those days are behind me.

The inability to track PDP applications came to a head for me last year when several applications were MIA and clients never received their policy. Going forward, I will continue to run drug reports, answer questions and offer advice . . . but I will not submit applications.

In over 50 years of helping individuals with their health insurance questions I have never been personally sued . . . and have never had to file an E&O claim. Error and omission carriers will not pay claims where the agent is not appointed with a carrier. Rather than assuming the risk myself, I am going to avoid the risk going forward.

GOVERNMENT (TAXPAYER) FUNDING DOESN’T LAST FOREVER

ACA (Obamacare) subsidies, Medicaid, Medicare, Part D.

MA funding only seems to increase and almost zero accountability

In 2021 the ESTIMATED Congressional funding allocated for Part D was $96 billion dollars . . . in 2022 the allocated amount was $3 billion . . . in 2023 the allocation was $121 billion  . . . in 2024 the amount was  . . . not disclosed . . .

Short answer, Part D, like other Medicare programs, relies on specific DC funding . . . which changes from year to year, regardless of which party is controlling the purse strings. 

Some years they make specific allocations for Part D, other years they don’t.

Several factors are in play here, too numerous to list. This is merely a broad brush summary so you know a little bit about the WHY some things cost more.

THINGS TO CONSIDER IN EVALUATING A DRUG PLAN

STAR RATING

Plans are rated from 1 to 5 stars. Most plans are 3.5 and higher, anything lower is generally caused by consumer complaints. I would avoid plans with star ratings below 3.

There are no 5 star plans in Georgia.

FORMULARY

The plan formulary determines which drugs are covered along with their tier rating. 

Tier 1 drugs are almost always low cost generics, and usually have a copay of $5 or less for a 30 day supply. Plan deductibles may not apply to tier 1 drugs.

Tier 2 drugs are higher cost generics and maybe a few brand name drugs.

Tier 3 are preferred brand name drugs. Preferred usually have a lower than non-preferred drugs . . . especially if filled at a preferred pharmacy.

Tier 4 drugs are non-preferred and have a higher copay vs. similar drugs on tier 3.

Tier 5 drugs are higher cost brand name & generics. Tier 5 drugs usually come with more restrictions than lower tier drugs.

Not all drugs have a flat dollar amount copay. Typically, tier 3 and higher require you to pay a percent of the formulary “retail” price of the drug. The coinsurance amount usually ranges from 25% to 50%.

Drugs with coinsurance mean the amount you pay for the medication can vary during the year. If the cost increases during the year, the amount you pay goes up by an equal percentage.

Only formulary drugs are included in the 2026 out of pocket cap of $2100. 

GENERICS are often less expensive when filling in 90 day increments. Consider using a discount card such as GoodRx or SingleCare vs. your drug plan.

GENERICS are usually, but not always, less expensive than brand name drugs.

UNCERTAIN FUTURE OF MEDICARE PART D PLANS

Ahead of Medicare’s annual mid-year announcement about the national average premium for Part D prescription drug coverage in 2026 and other plan details, two questions loom large for the insurers that sponsor Part D stand-alone prescription drug plans (PDPs) and the 23 million people in traditional Medicare who are currently enrolled in these plans.  

https://www.kff.org/medicare/the-uncertain-future-of-medicares-stand-alone-prescription-drug-plan-market-and-why-it-matters/

COMMENTARY . . .

“I am from the government and I am here to help” . . . the most frightening words in the English language.

Most of the problems we have are created by the government under the guise of wanting to help the citizens. Part D was a good idea that has gone bad.

Prior to 2006, seniors did not have a drug plan benefit, and there was no OOP cap on the cost of medications. There was also more help from private organizations offering a PAP (prescription assistance program). Most of those went away when Part D went into effect.

After 2006, the average retail prices of widely used prescription drugs, especially those for chronic conditions, outpaced the rate of general inflation.

The average retail price of brand-name drugs saw substantial increases, more than doubling in inflation-adjusted dollars since 2009.

New, high-cost brand-name drugs, some of which offered treatment for previously untreatable conditions, contributed to increased spending. Additionally, some manufacturers were able to create or exploit monopolies for certain drugs, leading to sustained high prices.

Economists know that when the cost of goods is subsidized, by insurance coverage or government (taxpayer) “contributions”, the result is always higher prices.

The Catch-22 is, once the government starts “paying” for something they will never cut back. Rather, the underlying cost of the product will be shifted to the consumer and politicians on both sides of the aisle will blame the other.

Brand name prescription drug prices for 2026 will be higher, including those imported from Canada and other non-U.S. sources. I hope to have more input on this in a future newsletter but for now, my Magic 8 ball says the future is cloudy.

19 Comments Southerners Won’t Tolerate

(Almost) everything from the way we talk, to what we eat and other stuff as well.

https://globegrazers.com/19-comments-southerners-wont-tolerate-even-if-you-meant-no-harm

In Closing . . .

I will not apologize for this long newsletter. Too many changes that impact almost everyone to let it slide.

First and foremost, I am not going to leave anyone hanging. I will still run drug reports and answer questions, but enrolling clients in new plans at renewal has become an impossible task. Something had to give.

A few years ago I tried farming out this task to another agency and that was a disaster. This is a compromise where I will do everything EXCEPT enroll you in a new plan.

This is a VERY LONG newsletter but so many things were too important to leave out.

Please take the time to read and feel free to ask questions by email.

Also, pass this along to your friends.

And finally, feedback is ALWAYS appreciated!

Bob & Rachel