Medicare Part D

Switching Drug Coverage in Erlanger? Know the Part D Cap First

# Switching Drug Coverage in Erlanger? Know the $2,100 Rule…

ERLANGER, Ky. — If you take even one prescription regularly, the way you get your Medicare drug coverage matters. In and around Erlanger, some neighbors get their drug benefits through a stand-alone Part D plan paired with Original Medicare. Others get drug coverage bundled inside a Medicare Advantage plan. Both paths are legitimate, but they work differently — and moving from one to the other changes more than just your pharmacy card.

Two structures, one goal

The first path is Original Medicare (Parts A and B) plus a stand-alone Part D prescription drug plan, sometimes called a PDP. Medicare handles your hospital and doctor visits, and a separate private plan handles your prescriptions.

The second path is Medicare Advantage (Part C). These plans, offered by private insurers, replace how you receive your Part A and Part B benefits and, in most cases, roll prescription drug coverage into the same plan. That kind of Advantage plan is often called an MA-PD.

Erlanger sits in Kenton County, where residents typically have a range of both stand-alone Part D plans and Medicare Advantage plans with drug coverage to choose from. The exact list changes each year, and you can compare current options on medicare.gov.

What the two paths share

No matter which door you walk through, the same federal Part D rules apply to your drug benefit:

• The out-of-pocket cap on covered prescriptions is $2,100 in 2026 and $2,400 in 2027.
• The maximum plan deductible for Part D is $615 in 2026 and $700 in 2027.
• The old coverage gap — the "donut hole" — was eliminated in 2025, leaving three simpler payment phases.
• The Medicare Prescription Payment Plan lets you spread your yearly drug costs into monthly bills instead of paying big amounts at the pharmacy.
• Higher-income enrollees may pay an IRMAA surcharge on Part D; for 2026, that starts above $109,000 in income for a single filer.

These figures come from CMS's Part D program rules and apply whether your drug coverage is stand-alone or bundled.

What actually changes if you switch

Moving between the two structures affects more than your prescriptions.

Going from Part D + Original Medicare to a Medicare Advantage plan with drugs. You'll generally use the Advantage plan's provider network for doctors and hospitals, and its pharmacy network and formulary for prescriptions. Referral and prior-authorization rules may look different. Your Part D coverage folds into the new plan; you should not enroll in a separate PDP on top of it.

Going from a Medicare Advantage plan back to Original Medicare + stand-alone Part D. You'll need to actively pick a stand-alone Part D plan so you don't have a gap in drug coverage (and don't risk a late-enrollment penalty later). You'll also want to think about a Medigap policy to help with Original Medicare's out-of-pocket costs. In Kentucky, guaranteed-issue rights for Medigap are limited to specific situations, so a switch back can affect what supplement coverage you can get and at what price. A licensed agent or your local SHIP counselor can walk you through the details.

When you can make the change

Most people make changes during one of two windows:

• Annual Enrollment Period, Oct. 15–Dec. 7. You can join, drop, or switch Part D and Medicare Advantage plans. Changes take effect Jan. 1.
• Medicare Advantage Open Enrollment Period, Jan. 1–March 31. If you're already in a Medicare Advantage plan, you can switch to a different Advantage plan or drop back to Original Medicare and add a stand-alone Part D plan.

Special Enrollment Periods may also apply if you move, lose other coverage, or qualify for Extra Help.

Questions to ask before you switch

• Are my regular medications on the new plan's formulary, and at what tier?
• Is my pharmacy in the network?
• If I'm leaving Medicare Advantage, do my doctors accept Original Medicare, and can I get the Medigap policy I want?
• Will the change affect any extra benefits I currently use?

Where to get help in northern Kentucky

For personalized answers, call 1-800-MEDICARE (TTY 1-877-486-2048), visit medicare.gov to compare plans by ZIP code, or contact the Kentucky State Health Insurance Assistance Program (SHIP), which offers free, unbiased counseling to people with Medicare and their families.