Medicare Part D

Switching Between Part D and Advantage? Read This First

Switching Between Part D and Advantage? Read This First — plain-language Medicare information for Auburn, New York.

AUBURN, N.Y. — If you take even one prescription, how you get your Medicare drug coverage matters. And in 2026, with a new $2,100 cap on what you pay out of pocket for covered drugs at the pharmacy, more people in and around Auburn are taking a fresh look at the two paths available to them.

Those two paths are simple to name but different in the details. You can pair Original Medicare (Parts A and B) with a stand-alone Part D drug plan. Or you can enroll in a Medicare Advantage plan that already includes drug coverage — often called an MA-PD. Both cover prescriptions under the same Part D rules, but the packaging, the cards in your wallet, and what happens when you switch are not the same.

The two structures, side by side

With Original Medicare plus stand-alone Part D, you have two separate pieces of coverage. Original Medicare (run by the federal government) pays for hospital and doctor services. A private Part D plan, which you choose separately, pays for your prescriptions. You can add a Medigap (Medicare Supplement) policy to help with what Original Medicare doesn't cover.

With a Medicare Advantage plan that includes drug coverage, one private plan handles everything — hospital, medical, and prescriptions — under a contract with Medicare. Many of these plans use provider networks and may include extras Original Medicare doesn't offer. You cannot pair a Medigap policy with an Advantage plan.

Auburn is in Cayuga County, and like the rest of New York, residents here have both stand-alone Part D plans and Medicare Advantage plans with drug coverage to choose from. The specific options change each year, which is one reason it pays to look during Open Enrollment even if you're happy with what you have.

What stays the same under both paths

The core Part D rules apply no matter which path you pick. For 2026:

• The out-of-pocket maximum for covered drugs is $2,100. Once you hit it, you pay $0 for covered prescriptions the rest of the year.
• The maximum Part D deductible any plan can charge is $615.
• The old coverage gap (the "donut hole") is gone as of 2025. Part D now has three phases: deductible, initial coverage, and catastrophic.
• The Medicare Prescription Payment Plan lets you spread your drug costs across the calendar year in monthly payments instead of paying big bills at the pharmacy counter. You can opt in with either type of plan.
• IRMAA — the income-related surcharge on Part B and Part D premiums — kicks in above $109,000 for a single filer in 2026.

What actually changes when you switch

Moving between the two structures affects more than just your pharmacy card.

Moving from Original Medicare + Part D into a Medicare Advantage plan: You'll generally use the Advantage plan's network of doctors and hospitals. Referrals or prior authorizations may apply. You keep paying your Part B premium. If you had a Medigap policy, you don't need it while you're in Advantage — but dropping it can be a one-way door in most states, because guaranteed-issue rights to buy Medigap later are limited.

Moving from Medicare Advantage back to Original Medicare + Part D: You'll want to actively enroll in a stand-alone Part D plan during the same window, or you could face a late enrollment penalty later. You'll also want to think about Medigap. Outside of a few protected situations, insurers can consider your health history when you apply, which may affect price or approval.

Moving from one stand-alone Part D plan to another, or one MA-PD to another: Simpler. You pick the new plan during a valid enrollment period, and your old coverage ends automatically when the new one starts.

The deadlines to circle

Two windows do most of the work:

• Annual Enrollment Period: Oct. 15 – Dec. 7. Anyone with Medicare can join, drop, or switch a Part D plan, or move between Original Medicare and Medicare Advantage. Changes take effect Jan. 1.
• Medicare Advantage Open Enrollment Period: Jan. 1 – March 31. If you're already in a Medicare Advantage plan on Jan. 1, you get one chance to switch to a different Advantage plan or return to Original Medicare (with a Part D plan). You cannot use this window to leave Original Medicare and join Advantage.

Special Enrollment Periods may apply if you move, lose other coverage, or qualify for Extra Help. If you're unsure whether one applies to you, call 1-800-MEDICARE before you make a change.

A few things worth checking before you move

Before switching from one structure to the other, it helps to answer these questions for yourself:

• Are the specific drugs you take on the new plan's formulary, and at what tier?
• Are your doctors and preferred pharmacies in the new plan's network?
• Would losing (or keeping) a Medigap policy affect your finances if your health changes?
• Do you travel or split time between states? Original Medicare and Advantage handle out-of-area care differently.

None of these have universal right answers. They depend on your health, your budget, and how you use care.