Medicare Supplement

Lexington Medicare Part D: cap, coverage gap, payment plan

LEXINGTON, Ky. — Starting Jan. 1, 2026, no one with Medicare Part D will pay more than $2,100 out of pocket for covered prescription drugs in a calendar year. That figure — a modest bump from the 2025 cap of $2,000 — is the headline change heading into this fall's Annual Enrollment Period, which runs from Oct. 15 through Dec. 7.

Lexington seniors will see a firm ceiling on drug costs in 2026

For Lexington residents managing expensive medications, the cap is the most meaningful shift in Part D since the program began in 2006. Here's how it works, and what else is changing.

The $2,100 cap, in plain English

Once your out-of-pocket spending on covered Part D drugs hits $2,100 in 2026, you pay $0 for the rest of the year on those covered prescriptions. That's it. No more open-ended costs, no more coverage gap to worry about.

A few things to know:

• The cap applies to covered drugs on your plan's formulary. Drugs your plan doesn't cover don't count toward it.
• Premiums you pay each month do not count toward the $2,100.
• The maximum Part D deductible in 2026 is $615, though many plans set theirs lower.

The "donut hole" is gone

If you remember the old coverage gap — that stretch where you suddenly paid a bigger share of your drug costs — it's no longer part of the program. Since 2025, Part D has had just three phases:

1. Deductible phase — you pay full negotiated price until you meet your plan's deductible. 2. Initial coverage phase — you pay a copay or coinsurance; the plan pays the rest. 3. Catastrophic phase — once you hit the annual out-of-pocket cap, you pay nothing more for covered drugs.

That's a simpler structure than we've had in nearly two decades.

The Medicare Prescription Payment Plan: spreading the cost

Even with a $2,100 ceiling, hitting a big pharmacy bill in January can sting. That's where the Medicare Prescription Payment Plan comes in. It's a free, optional program that lets you spread your drug costs across the calendar year in monthly installments instead of paying the pharmacy in full at pickup.

A few honest notes:

• You still owe the same total amount — it's smoothed, not reduced.
• You can opt in before the plan year or during it, through your Part D or Medicare Advantage drug plan.
• It tends to help most if you have high costs early in the year or take one or two expensive medications.

Anyone with Part D coverage is eligible. Ask your plan how to enroll.

Higher-income enrollees: IRMAA thresholds

If your 2024 income (used for 2026) was above $109,000 as a single filer — or $218,000 filing jointly — you'll pay an Income-Related Monthly Adjustment Amount (IRMAA) on top of your Part D and Part B premiums. IRMAA is set by the Social Security Administration, not your plan, and you can appeal if you've had a major life change like retirement or the loss of a spouse.

What Lexington residents should do this fall

Lexington is in Fayette County, where Medicare beneficiaries choose from a range of stand-alone Part D and Medicare Advantage drug plans each year. Plan availability, formularies, and pharmacy networks are set at the county level, and they change annually — so a plan that worked in 2025 may look different in 2026.

Practical steps before Dec. 7:

• Read your Annual Notice of Change (ANOC) from your current plan. It arrives in September.
• Check that your drugs are still on the formulary and that your pharmacy is still in-network.
• Use the Plan Finder at Medicare.gov to compare options side-by-side.
• Call Kentucky SHIP (State Health Insurance Assistance Program) for free, unbiased help.