Medicare Part D

Switching between Part D and Advantage drug coverage? Read this first

In South Charleston, many people on Medicare end up with prescription drug coverage in one of two very different ways. Some pair Original Medicare with a stand-alone Part D drug plan. Others pick a Medicare Advantage plan that already has drug coverage rolled in. Both paths can get your prescriptions covered — but they are built differently, and moving from one to the other changes more than just your drug card.

Two different structures, same goal

A stand-alone Part D plan is exactly what it sounds like: a separate plan that only covers prescription drugs. You keep Original Medicare (Parts A and B) for your hospital and doctor coverage, and you add a Part D plan on top. Many people in this setup also carry a Medigap (Medicare Supplement) policy to help with what Original Medicare does not pay.

A Medicare Advantage plan with drug coverage — often called an "MA-PD" — bundles everything into one plan run by a private insurer. Your hospital, doctor, and drug benefits are managed together, usually with a network of providers and pharmacies. You still have Medicare; the Advantage plan is simply the way you get those benefits.

South Charleston is in Kanawha County, where residents typically have both stand-alone Part D plans and Medicare Advantage plans with drug coverage to choose from during enrollment periods. The exact count changes each year, and Medicare.gov's Plan Finder shows what is available for your ZIP code.

The rules that apply to both

No matter which path you take, the core Part D rules are the same in both 2026 and 2027:

• The Part D deductible cannot be more than $615 in 2026, rising to $700 in 2027.
• Once your out-of-pocket spending on covered drugs hits the annual cap — $2,100 in 2026 and $2,400 in 2027 — you pay nothing for the rest of the year on those drugs.
• The old "donut hole" coverage gap 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 into monthly payments instead of paying big amounts at the pharmacy counter. You can opt in through your plan.
• Higher-income enrollees may pay an IRMAA surcharge on Part D. For 2026, IRMAA starts above $109,000 in income for a single filer.

These rules follow you whether your drug coverage sits inside a stand-alone Part D plan or inside a Medicare Advantage plan.

What actually changes if you switch paths

Moving between the two paths is not just a paperwork swap. Here is what tends to shift:

Your doctor and hospital coverage. Going from Original Medicare + Part D into a Medicare Advantage plan means your medical care now runs through the Advantage plan's network and rules. Going the other direction — leaving Advantage for Original Medicare + a stand-alone Part D — means you may want to look at a Medigap policy to help with Original Medicare's cost-sharing. Medigap rights depend on timing and your state.

Your pharmacy network and drug list. Each plan has its own formulary (the list of covered drugs) and its own preferred pharmacies. A medication that is easy to fill under one plan may be tiered differently, need prior authorization, or be excluded under another. Always check the formulary before switching.

Extra benefits. Some Medicare Advantage plans include extras that Original Medicare does not cover. If you leave Advantage, those extras go away. That is a fair trade-off to consider, but it should not be the only factor.

How you handle problems. With Original Medicare + Part D, you have two separate customer service lines — one for Medicare, one for your drug plan. With Advantage, one plan handles most everything, but you follow that plan's appeal and grievance process.

When you can make a change

Two windows matter most:

• Annual Enrollment Period, October 15 – December 7. Anyone with Medicare can switch between Original Medicare and Medicare Advantage, change Part D plans, or join or drop drug coverage. Changes take effect January 1.
• Medicare Advantage Open Enrollment, January 1 – March 31. If you are already in a Medicare Advantage plan on January 1, you can switch to another Advantage plan or return to Original Medicare (and pick up a stand-alone Part D plan) once during this window.

Some people also qualify for a Special Enrollment Period — for example, after moving or losing other coverage. If you think one applies to you, call 1-800-MEDICARE to confirm.

Before you move between the two paths

A short checklist can save headaches later:

• List every medication you take, including dose and frequency, and check it against the new plan's formulary.
• Confirm your doctors, specialists, and preferred pharmacy are in the new plan's network if you are considering Medicare Advantage.
• If you are leaving Medicare Advantage for Original Medicare, ask about Medigap eligibility in West Virginia before you drop the Advantage plan.
• Write down when your new coverage starts so you do not have a gap at the pharmacy on January 1.

West Virginia SHIP counselors offer free, one-on-one Medicare help and do not sell plans. They are a good stop before making a switch.