Medicare Part D

Medicare's New $2,100 Drug Cap: What Changes in 2026

UPPER DARBY, Pa. — Starting January 1, 2026, Medicare's prescription drug coverage will look different than it did just a few years ago. The biggest change: once you spend $2,100 out of pocket on covered drugs in a calendar year, you pay $0 for the rest of the year on those drugs. That single number — $2,100 — is the new ceiling for Part D costs in 2026, up from $2,000 in 2025.

A big shift for Part D starts January 1

For people in Upper Darby comparing coverage during the Annual Enrollment Period (October 15 – December 7), this is a rule worth understanding before you pick a plan.

The $2,100 cap, in plain English

The out-of-pocket cap applies to what you personally spend on prescription drugs that your Part D plan covers. That includes your deductible and your share of drug costs at the pharmacy. It does not include your monthly premium.

Once your out-of-pocket spending hits $2,100, you move into what Medicare calls the "catastrophic" phase, and you owe nothing more for covered drugs that year. The cap resets every January 1.

A few other 2026 figures worth knowing, according to CMS:

• The maximum Part D deductible a plan can charge is $615.
• Higher-income enrollees pay an IRMAA surcharge on Part D; for single filers, that kicks in above $109,000 in income (based on your 2024 tax return).

The "donut hole" is gone

If you or a family member has been on Medicare for a while, you probably remember the coverage gap — the so-called "donut hole" — where costs jumped in the middle of the year after you'd used a certain amount of coverage.

That gap was eliminated in 2025. Part D now has just three phases:

1. Deductible — you pay full negotiated cost until you meet the plan's deductible (up to $615). 2. Initial coverage — you pay a share (usually 25%) until your out-of-pocket total reaches $2,100. 3. Catastrophic — you pay $0 for covered drugs the rest of the year.

No more surprise price jump halfway through the year. That's the biggest structural change most people will feel.

The Medicare Prescription Payment Plan

Hitting $2,100 sounds manageable spread across 12 months — but what if a big prescription bill lands in January? That's where the Medicare Prescription Payment Plan comes in.

This is a free, optional program (sometimes called "M3P" or drug cost smoothing). Instead of paying the pharmacy the full amount at pickup, you pay $0 at the counter, and your Part D plan bills you monthly for what you would have owed — spread across the rest of the calendar year.

A few things to know:

• It doesn't lower your total drug costs; it just spreads them out.
• You have to opt in through your Part D plan (or the Part D portion of a Medicare Advantage plan).
• It tends to help most if you have expensive medications early in the year.
• If you take only low-cost generics, the extra paperwork may not be worth it.

You can sign up before the plan year starts or any time during the year.

What this means when you compare coverage

Upper Darby is in Delaware County, where residents have a wide range of stand-alone Part D plans and Medicare Advantage plans with drug coverage to choose from during Open Enrollment. The $2,100 cap applies across all of them — it's a federal rule, not a plan feature.

That means, when you're comparing options, the questions to ask are less about "is there a cap?" (yes, everywhere) and more about:

• Is my specific drug on the plan's formulary (covered list)?
• What tier is it on, and what's the cost share before I hit the cap?
• Does the plan use my regular pharmacy as a preferred pharmacy?
• Do I want to enroll in the payment plan to smooth out costs?

The Plan Finder at medicare.gov lets you enter your drugs and pharmacy and see estimated yearly costs for each plan available in your ZIP code.

Dates to keep on the calendar

• October 15 – December 7, 2025: Annual Enrollment Period. Join, switch, or drop a Part D or Medicare Advantage plan. Changes take effect January 1, 2026.
• January 1 – March 31, 2026: Medicare Advantage Open Enrollment. If you're already in a Medicare Advantage plan, you can switch to a different one or return to Original Medicare (and add a Part D plan).