Medicare Supplement

Why Medigap skips the pharmacy counter — and how New Rochelle readers add Part D on time

NEW ROCHELLE, N.Y. — If you pair Original Medicare with a Medigap policy, you have strong coverage for doctors and hospitals — but not for the medicine you pick up at the pharmacy. That is a common surprise, and it is the reason a stand-alone Part D drug plan is usually the third piece of the puzzle. Getting the timing right also keeps a small monthly penalty from following you for the rest of your life.

Medicare SupplementNew Rochelle, NY

Here is how the three pieces fit, and the deadlines to watch.

The three pieces, in plain English

Original Medicare is the federal program. Part A covers hospital stays; Part B covers doctor visits and outpatient care. It pays most of the bill, but not all of it, and it does not cover most retail prescriptions.

Medigap (also called Medicare Supplement Insurance) is a private policy that helps pay the out-of-pocket costs Original Medicare leaves behind — things like coinsurance and hospital deductibles. Medigap plans sold today are not allowed to include drug coverage.

Part D is the separate, private prescription drug plan you add on. It has its own monthly premium, its own pharmacy network, and its own list of covered drugs (the formulary).

Put together, the pattern looks like this: Original Medicare pays first, Medigap picks up much of what is left on the medical side, and Part D handles the pharmacy side.

Why Medigap does not cover prescriptions

Older Medigap policies once included some drug coverage, but that changed when Congress created Part D in 2006. Since then, new Medigap policies have not been allowed to include prescription benefits. If you have a very old Medigap policy that still includes drugs, it may not be considered “creditable” compared with a Part D plan — a call to your plan or to your local SHIP counselor can confirm.

The upshot: if you want help paying for prescriptions and you are on Original Medicare with Medigap, you need a stand-alone Part D plan.

The timing that keeps you out of the Part D penalty

The Part D late enrollment penalty is small but permanent. It gets added to your monthly Part D premium for as long as you have Part D coverage.

You can avoid it by doing one of two things:

• Enroll in Part D when you are first eligible. For most people, that is the 7-month window around your 65th birthday — the three months before your birthday month, your birthday month, and the three months after.
• Keep “creditable” drug coverage — coverage at least as good as Part D — without a break of 63 days or more. Employer, union or VA drug coverage often counts. The plan should send you a yearly notice telling you whether it is creditable. Keep those notices.

If you drop creditable coverage later (say, you retire), you generally have a 63-day window to pick up a Part D plan before the penalty clock starts.

Outside of your first eligibility window, most people change or add Part D during the Annual Enrollment Period, Oct. 15 to Dec. 7, for coverage that starts Jan. 1.

What Part D looks like in 2026

A few numbers worth knowing for the year ahead:

• The annual out-of-pocket cap for covered Part D drugs is $2,100. Once you hit it, you pay nothing more for covered prescriptions the rest of the year.
• The maximum deductible any Part D plan can charge is $615. Some plans charge less.
• The old coverage gap (“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 year in level monthly payments instead of paying big amounts at the pharmacy counter. It does not lower the total; it just smooths it out.
• If your income is above $109,000 (single filer, 2026), an IRMAA surcharge is added to your Part B and Part D premiums.

Choosing a Part D plan in Westchester County

New Rochelle is in Westchester County, where multiple stand-alone Part D plans are sold by private insurers under Medicare’s rules. Plans differ in premium, deductible, pharmacy network and — most importantly — which drugs are on the formulary and at what tier.

A useful way to compare:

1. Make a list of your current prescriptions, including dose and how often you fill them. 2. Use the Plan Finder at medicare.gov to enter that list and see how each plan would price your specific drugs at nearby pharmacies. 3. Check whether your regular pharmacy is in the plan’s preferred network. 4. Look at the plan’s rules for prior authorization or step therapy on any drug you take.

For free, unbiased help, New York’s State Health Insurance Assistance Program (SHIP) is called HIICAP. Counselors can walk through the comparison with you at no cost.