Updated for 2026 | By Mauldin Insurance Group | Lexington, South Carolina

 

 

If you’re on Medicare or turning 65 soon, there has never been a better time to understand your prescription drug coverage. Thanks to major changes brought by the Inflation Reduction Act of 2022 (IRA), Medicare Part D in 2026 looks significantly different — and more favorable — than it did just a few years ago. This guide explains everything South Carolina residents need to know about Medicare Part D for 2026, including the new out-of-pocket cap, the elimination of the coverage gap, negotiated drug prices, and how Mauldin Insurance Group can help you find the right plan.

 

What Is Medicare Part D?

Medicare Part D is the federal program that provides prescription drug coverage to Medicare beneficiaries. It was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and took effect in 2006. Part D coverage is offered through private insurance companies approved by Medicare and is available either as a stand-alone Prescription Drug Plan (PDP) paired with Original Medicare, or bundled into a Medicare Advantage plan with drug coverage (MA-PD).

The program helps reduce out-of-pocket costs for the medications you need — and in 2026, new provisions are making it more affordable than ever before.

 

What’s New in 2026: The Biggest Changes to Medicare Part D

The Inflation Reduction Act has reshaped Medicare Part D in several important ways. Here’s what every South Carolina Medicare beneficiary needs to know heading into 2026:

 

1. The Out-of-Pocket Cap Is $2,100 in 2026

One of the most significant improvements to Medicare Part D is the new cap on out-of-pocket drug costs. In 2025, the cap was $2,000 — the first time Medicare ever set a hard annual limit on what beneficiaries pay for covered drugs. In 2026, that cap increases slightly to $2,100 due to an annual inflation adjustment tied to the growth of average Part D drug spending.

Once you spend $2,100 out-of-pocket on covered drugs in a calendar year, you automatically enter the Catastrophic Coverage phase — and you pay nothing more for your covered medications for the rest of that year. This cap applies whether you are in a stand-alone Part D plan or a Medicare Advantage plan with drug coverage.

💡 What counts toward the $2,100 cap? Your deductible, copayments, coinsurance, and certain payments made on your behalf (such as through the Extra Help program) all count toward the cap. Monthly premiums do NOT count.

 

2. The Coverage Gap (“Donut Hole”) Is Gone

Prior to 2025, millions of Medicare beneficiaries fell into the notorious “coverage gap” — also called the donut hole — where they were responsible for a much larger share of their drug costs. As of 2025, the coverage gap has been permanently eliminated under the IRA. In 2026, standard Part D coverage has only three straightforward phases:

• Deductible Phase: You pay the full cost of covered drugs until you meet your deductible (up to $615 in 2026).
• Initial Coverage Phase: After your deductible, you pay 25% of drug costs as coinsurance until your out-of-pocket total reaches $2,100.
• Catastrophic Coverage Phase: Once you hit $2,100 in out-of-pocket costs, your covered drugs cost you nothing for the remainder of the year.

There is no longer a fourth “donut hole” phase where your costs spike. This makes budgeting for medications much more predictable.

 

3. Negotiated Drug Prices Take Effect for 10 High-Cost Medications

For the first time in Medicare’s history, the federal government has directly negotiated lower prices for a group of commonly used, expensive brand-name drugs. These negotiated prices — called Maximum Fair Prices (MFPs) — took effect January 1, 2026, and are expected to save enrolled beneficiaries approximately $1.5 billion in out-of-pocket costs this year.

All Medicare Part D plans and Medicare Advantage plans with drug coverage are required to include these 10 medications on their formularies. If you take any of these drugs, you may see lower copays or coinsurance when you fill your prescription:

• Eliquis (blood clots/AFib)
• Xarelto (blood clots/AFib)
• Jardiance (diabetes/heart failure)
• Januvia (type 2 diabetes)
• Farxiga (diabetes/heart failure/kidney disease)
• Enbrel (rheumatoid arthritis/psoriasis)
• Stelara (psoriasis/Crohn’s disease)
• Entresto (heart failure)
• Imbruvica (certain blood cancers)
• Fiasp/NovoLog (insulin for diabetes)

Note: Because each Part D plan structures cost-sharing differently, actual savings will vary by plan. Contact Mauldin Insurance Group to review which plan gives you the best value for your specific medications.

 

4. The Medicare Prescription Payment Plan (MPPP) Continues

Introduced in 2025 and continuing in 2026, the Medicare Prescription Payment Plan allows you to spread your expected out-of-pocket drug costs evenly across all 12 months of the year rather than paying large amounts early in the year when deductibles reset. This is especially useful for people who take high-cost medications and typically hit their $2,100 cap in the first few months of the year.

Example: If you expect $2,100 in out-of-pocket drug costs for the year, enrolling in the MPPP would let you pay approximately $175 per month instead of paying the full amount at once. Ask your Part D plan about this option — some plans auto-enroll eligible members.

 

5. $35 Insulin Cap and Free Vaccines Continue

Also continuing in 2026 under the IRA:

• Insulin is capped at $35 per month (or 25% of the plan’s negotiated price, whichever is less) for all Part D enrollees.
• All adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) — including the shingles vaccine, Tdap, and others — are covered with $0 cost-sharing under Part D.

 

2026 Medicare Part D: Key Cost Numbers at a Glance

 

Cost Item	2026 Amount
Maximum Annual Deductible	Up to $615 (plans may offer less or $0)
Out-of-Pocket Cap	$2,100 (after which covered drugs are $0)
Initial Coverage Coinsurance	25% of drug cost after deductible
Insulin Cost Cap	$35/month maximum
Recommended Vaccines	$0 cost-sharing
National Base Beneficiary Premium	$38.99/month (varies by plan)
Late Enrollment Penalty	1% per uncovered month x $38.99

 

Who Is Eligible for Medicare Part D in South Carolina?

You may enroll in Medicare Part D if you are enrolled in Medicare Part A and/or Part B. This includes:

• South Carolina residents age 65 and older
• Individuals under 65 with qualifying disabilities who receive Social Security Disability Insurance (SSDI) for at least 24 months
• Individuals with End-Stage Renal Disease (ESRD)
• Individuals with Amyotrophic Lateral Sclerosis (ALS) — eligible immediately upon Medicare enrollment

If you have creditable drug coverage through an employer or retiree plan, you may delay Part D enrollment without a penalty. However, it is important to confirm that your coverage qualifies as creditable — this determination changed under the IRA. Ask Mauldin Insurance Group to help you verify.

 

Medicare Part D Enrollment Periods in 2026

Enrolling at the right time is critical to avoiding late enrollment penalties. Here are the key enrollment windows:

 

Initial Enrollment Period (IEP)

A 7-month window that begins 3 months before the month you turn 65, includes your birthday month, and ends 3 months after. This is your first and best opportunity to enroll in Medicare Part D without a penalty.

 

Annual Enrollment Period (AEP) — Open Enrollment

October 15 through December 7 each year. During this window, you can join, switch, or drop a Medicare drug plan. Changes take effect January 1 of the following year. This is the time to shop plans and make sure your coverage still fits your needs — formularies, premiums, and covered pharmacies can change every year.

 

Medicare Advantage Open Enrollment Period

January 1 through March 31 each year. If you are enrolled in a Medicare Advantage plan, you can switch to a different MA plan or return to Original Medicare (and enroll in a stand-alone Part D plan).

 

Special Enrollment Periods (SEPs)

Life events such as losing employer coverage, moving to a new service area, or qualifying for Extra Help may trigger a Special Enrollment Period that lets you change or add Part D coverage outside of the standard windows.

 

NEW for 2026: MA Plan Finder SEP

New in 2026, if you enrolled in a Medicare Advantage plan based on inaccurate provider directory information and discover your doctors are not actually in-network within the first three months, you may be eligible for a Special Enrollment Period to switch to a different plan or return to Original Medicare.

 

⚠️ Avoid the Late Enrollment Penalty If you go 63 or more consecutive days without creditable prescription drug coverage after your Initial Enrollment Period ends, you may face a permanent Part D late enrollment penalty. The penalty is 1% of the national base beneficiary premium ($38.99 in 2026) for every uncovered month. It is added to your premium for as long as you have Part D coverage.

 

How to Choose the Right Medicare Part D Plan in South Carolina

With dozens of plan options available, choosing the right Part D plan requires comparing several key factors:

 

Step 1: List Your Medications

Write down every prescription you take, including dosage and how often you fill it. This is the foundation of any good plan comparison.

 

Step 2: Check the Formulary

Every Part D plan has a formulary — a list of covered drugs organized by tiers. Lower tiers typically have lower copays; higher tiers (including specialty drugs) cost more. Make sure your specific medications are on the formulary, and check which tier they fall into.

 

Step 3: Calculate Your Total Annual Costs

Look beyond the monthly premium. Factor in the deductible, copays or coinsurance for each of your drugs, and whether the plan uses preferred pharmacies in your area. The plan with the lowest premium is not always the least expensive overall.

 

Step 4: Review Pharmacy Networks

Some plans offer lower cost-sharing at preferred pharmacies. Check whether your preferred local pharmacy is in-network and whether mail-order options could save you money.

 

Step 5: Work With a Local Expert

The Medicare Plan Finder at Medicare.gov is a helpful starting point, but navigating the options — especially with the new negotiated drug prices — can be complex. Working with an independent licensed insurance agent like Mauldin Insurance Group means you get personalized, unbiased guidance across multiple carriers, at no cost to you.

 

Low-Income Subsidies and Extra Help in 2026

If your income and resources are limited, you may qualify for Extra Help — a federal program that significantly reduces your Part D costs. Under the IRA, eligibility for full Extra Help expanded in 2024 to include individuals with income up to 150% of the Federal Poverty Level (FPL).

In 2026, full Extra Help means:

• No premium for the Part D benchmark plan
• No deductible
• Copays of only $5.10 for generics and $12.65 for brand-name drugs

Income limits for 2026: approximately $23,475 for a single individual and $31,725 for a married couple (continental U.S.). Asset limits are $17,600 for a single person and $35,130 for a couple.

You can apply for Extra Help through the Social Security Administration at SSA.gov or by calling 1-800-772-1213. Mauldin Insurance Group can also help you determine whether you qualify and how to apply.

 

Frequently Asked Questions About Medicare Part D in 2026

 

Is the coverage gap (donut hole) still a thing in 2026?

No. The coverage gap was eliminated as of 2025 under the Inflation Reduction Act. In 2026, Part D has three straightforward phases: deductible, initial coverage, and catastrophic. There is no longer a phase where your out-of-pocket costs spike.

 

Can I change my Part D plan in 2026?

Yes, during the Annual Enrollment Period (October 15–December 7) you can switch to any available Part D plan. You may also qualify for a Special Enrollment Period if you experience a life change such as losing other coverage, moving, or qualifying for Extra Help.

 

What if my medication is not covered by my plan’s formulary?

You have options: ask your doctor about a covered alternative, request a formulary exception from your plan, or switch to a plan during open enrollment that covers your medication. Mauldin Insurance Group can help you identify plans that cover your specific drugs.

 

What are the 10 drugs with newly negotiated prices in 2026?

Eliquis, Xarelto, Jardiance, Januvia, Farxiga, Enbrel, Stelara, Entresto, Imbruvica, and Fiasp/NovoLog. All Part D plans must include these drugs on their formularies. If you take one of these medications, contact your plan or pharmacist to understand how your specific cost-sharing is affected.

 

Will GLP-1 weight-loss drugs be covered under Part D in 2026?

Starting in mid-2026, certain GLP-1 medications (including Mounjaro, Ozempic, Wegovy, and Zepbound) are expected to be available to qualifying Medicare Part D enrollees at approximately $50/month through a CMS bridge program. This pilot is targeted at individuals with obesity and is expected to transition into a broader program in 2027. Check with your plan and doctor for eligibility details.

 

 

Ready to Review Your Part D Coverage?

At Mauldin Insurance Group, we help South Carolina residents find the Part D plan that covers their medications at the lowest total cost — not just the lowest premium. As an independent agency, we work with multiple carriers and have no reason to steer you toward any particular company. Our consultations are always free and always personalized.

📞 Call or Text: 843-509-2462

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