How to Plan Medicare Open Enrollment for Prescription Drug Coverage in 2026

Every year, Medicare beneficiaries miss out on hundreds of dollars in savings by not reviewing their prescription drug coverage during Medicare open enrollment. For 2026 coverage, the window to adjust your plan runs from October 15 to December 7, 2025. If you miss this window, you're stuck with your current plan for the entire year-even if your medications or health needs change. The Centers for Medicare & Medicaid Services (CMS) reports that beneficiaries who actively compare plans during this period save an average of $532 annually on prescription drug costs alone. That's money you're leaving on the table if you don't take action.

Medicare plans change their premiums, deductibles, and drug coverage every single year. A medication covered at Tier 2 last year could move to Tier 4 this year, increasing your out-of-pocket costs by 25-33%. According to Louise Norris, a licensed health insurance broker with 18 years of Medicare experience, "Plans change their formularies, networks, and costs every year-so reviewing them annually isn't optional. It's your best chance to save money." KFF's October 2024 analysis found that 78% of Medicare Advantage plans changed their provider networks between 2023 and 2024, which could mean your local pharmacy or doctor is no longer in-network. Ignoring these changes could cost you hundreds more each year.

Step-by-Step Guide to Planning Your Coverage

Here's a simple five-step process to make sure you're covered for the best medication costs in 2026:

1. Gather your current medications (October 1-10): Write down every prescription you take, including dosages and how often you take them. Don't forget over-the-counter drugs your doctor has approved. This is your baseline for comparison.
2. Review your current plan's documents (October 10-15): Check your Annual Notice of Change (ANOC) and Evidence of Coverage (EOC). These documents detail exactly what's changing for next year. If you don't have them, call your plan provider-they're required to send these by October 1.
3. Use the Medicare Plan Finder tool (October 15-20): Enter your medications and zip code. The tool compares all available plans side-by-side, showing monthly premiums, deductibles, and what your out-of-pocket costs would be for your specific drugs. Medicare.gov reports that beneficiaries who use this tool are 3.2 times more likely to find a lower-cost plan.
4. Verify pharmacy networks (October 20-25): Check if your preferred pharmacy is in-network. Many plans have preferred pharmacies with lower copays. For example, Walmart and Costco often have better pricing for generic drugs. If your pharmacy was removed from the network, you might need to switch plans.
5. Check supplemental benefits (October 25-30): If you're in a Medicare Advantage plan, review extra benefits like dental, vision, or gym memberships. These can add significant value beyond drug coverage.

According to the Medicare Rights Center's 2024 usability study, the average time commitment for this process is just 3.7 hours. That's less than one workday-and it could save you over $500 annually. State Health Insurance Assistance Programs (SHIP) offer free counseling in all 50 states. Find your local SHIP counselor at 1-800-MEDICARE or visit medicare.gov/ship.

Mastering the Medicare Plan Finder Tool

The Medicare Plan Finder tool is your best friend during open enrollment. Here's how to use it effectively:

• Enter your exact medications and dosages. Don't guess-use the exact name and strength. A common mistake is entering "Ozempic" without specifying the dosage (0.25mg, 0.5mg, etc.).
• Check "Total Cost" estimates. The tool shows estimated annual costs for your specific drugs, not just monthly premiums. A plan with a $0 premium might cost more overall if your medications aren't covered well.
• Sort by "Total Cost" instead of "Premium." This shows the real cost after deductibles and copays. For example, a plan with a $10 monthly premium but high drug copays might cost more than a $50 premium plan with better drug coverage.
• Use the "Formulary" tab to see if your medications are covered. Look for any restrictions like prior authorization or step therapy. KFF's 2025 analysis found that 50% of covered drugs in Part D plans have utilization management restrictions.
• Check "Pharmacy Network" to see which pharmacies offer the best prices. Preferred pharmacies often have lower copays. For instance, a generic drug might cost $5 at a preferred pharmacy but $20 at a standard pharmacy.

Medicare.gov's user survey from December 2024 found that beneficiaries who used the Plan Finder tool found plans with $1,200+ lower annual costs compared to those who didn't. The tool also includes new "total cost" calculators for 2026, which factor in recent changes from the Inflation Reduction Act. This means you'll get more accurate estimates for insulin and specialty drugs.

Decoding Formulary Changes and Pharmacy Networks

Formularies-the lists of drugs covered by your plan-change constantly. Here's what to look for:

Formulary tiers determine your cost-sharing. Tier 1 (generic) drugs usually have the lowest copays, while Tier 5 (specialty drugs) can cost hundreds per month. In 2025, 42% of Part D plans increased cost-sharing for specialty tier drugs, according to KFF's Tricia Neuman. For example, a drug like Humira might move from Tier 3 to Tier 4, increasing your copay from $50 to $120 per prescription.

Pharmacy networks matter just as much. If your local pharmacy isn't in-network, you'll pay significantly more. For instance, a $100 generic drug might cost $15 at a preferred pharmacy but $60 at a non-preferred one. KFF's data shows that 32% of Reddit Medicare users complained about pharmacies being removed from networks during open enrollment. Always verify your pharmacy's status in the Plan Finder tool.

Also check for "step therapy" requirements. This means you must try a cheaper drug before your prescribed one is covered. A 2024 Medicare Rights Helpline report found 68% of callers needed help understanding these restrictions. If your medication requires step therapy, you might need to switch plans to avoid delays in treatment.

Avoiding Costly Mistakes During Enrollment

Here are the most common errors-and how to avoid them:

• Missing the December 7 deadline: All changes must be made by December 7 to take effect January 1. CMS data shows 12% of first-time Medicare users miss this deadline. Set calendar reminders early.
• Ignoring formulary changes: A medication covered in 2024 might not be covered in 2025. Justice in Aging's 2025 guide found 60% of Part D plans change at least one medication's formulary status annually. Always check your specific drugs.
• Not reviewing pharmacy networks: If your pharmacy is no longer preferred, you'll pay more. The Medicare Rights Center documented cases where beneficiaries paid $400+ monthly because their pharmacy was removed from the network.
• Assuming your plan stays the same: Even if you're happy with your plan, review it. CMS data shows that 43% of Medicare Advantage plans changed their provider networks between 2023 and 2024.

Another pitfall is overlooking supplemental benefits. Medicare Advantage plans often include extra benefits like dental or vision. If you need these, check if they're still offered. Avalere Health predicts 15-20% of Medicare Advantage plans will modify their supplemental benefits for 2026 to comply with new CMS guidelines.

What's New for 2026 Coverage

The Inflation Reduction Act is making big changes to Medicare drug coverage. For 2026:

• Insulin cap at $35/month: All Part D plans must cover insulin at $35 per month. This applies to all types of insulin, including generics.
• Complete elimination of the "donut hole": The coverage gap is fully closed, so you'll never pay more than 25% for brand-name drugs in the catastrophic phase.
• New CMS requirements for Part B drugs: Starting January 1, 2026, Medicare Advantage plans must cover all Part B drugs administered in outpatient settings. This includes chemotherapy and other treatments you receive at a doctor's office.
• Improved Plan Finder tool: The tool now includes estimated annual costs for your specific medications, factoring in all recent changes.

The Medicare Payment Advisory Commission forecasts a 4.2% increase in average Part D premiums for 2026 due to new drug pricing provisions. But with these changes, many beneficiaries will still see net savings. For example, a beneficiary taking multiple insulin prescriptions could save $420 annually just from the $35 cap alone.

Frequently Asked Questions