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Hello Toni,

I delayed enrolling in Medicare Part B because I was working with employer benefits.  Recently I turned 70 and am retiring effective Jan. 1. I have enrolled in a Medicare Supplement Plan G and Part D prescription drug plan that also begin Jan 1.

Now my Medicare stress has started, because I have received a notice from the Centers for Medicare and Medicaid Services (CMS) saying they do not have a record of me having prescription drug coverage that “met Medicare’s minimum standards” from March 1, 2019, when I turned 65, to Jan. 1, 2026, when I retired, and I may receive a Part D Late Enrollment Penalty (LEP).

I thought applying for Part B with the form from my employer kept me from this Part D penalty. Can you please advise me what to do to keep from making a mistake? Thank you, Toni.

— Zach from Houston, Texas

Hi Zach:

Many Americans retiring after 65 and leaving their employer health insurance plan are discovering that they have to prove they had “creditable drug coverage” when enrolling in their new Medicare Part D prescription drug plan.

Zach, enrolling properly in Medicare Part B does not prove that your employer’s group prescription drug plan was creditable. The 2026 Medicare & You handbook states on page 84 under “There are 3 ways to avoid paying a penalty:”

1. Get Medicare drug coverage (Part D) when you’re first eligible for it. “Even if you don’t take drugs now…consider joining a separate Medicare drug plan or a Medicare Advantage Plan with drug coverage to avoid a penalty.”
2. Add Medicare drug coverage (Part D) if you lose other creditable coverage. “Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs (VA). Your plan must tell you each year if your non-Medicare drug coverage is creditable coverage. If you go 63 days or more in a row without Medicare drug coverage or other creditable prescription drug coverage, you may have to pay a penalty if you sign up for Medicare drug coverage later.”
3. Keep records showing when you had other creditable prescription drug coverage and tell your plan when they ask about it. “If you don’t tell your Part D plan about your previous creditable prescription drug coverage, you may have to pay a penalty for as long as you have Medicare drug coverage.”

Creditable drug coverage should “meet or exceed” Medicare’s Part D plan minimum. The minimum deductible for 2026 should not exceed $615. or less. The benefit amount should be unlimited, so if your plan has a coverage limit or cap, it is not creditable.

Discount prescription drug programs from Walmart, Kroger, GoodRx, Amazon pharmacy or your local pharmacy that offer low-cost generics do not count as creditable coverage.

Medicare can impose the Late Enrollment Penalty (LEP):

• Your company prescription drug benefits are not considered creditable, as determined by Medicare.
• You fail to call and confirm that your company prescription drug benefits were creditable, if requested via correspondence from your Part D plan. Zach, this is your Part D situation Don’t fail to confirm!
• You had no creditable coverage and never enrolled in Medicare Part D when you were first eligible.

If you wait longer than 63 days without creditable prescription drug coverage when leaving company benefits and are older than 65 years and   90 days old, you may receive a late enrollment penalty. For 2026 the penalty is 1% of the national Part D average or $.39 for each month back to the month your Part A began, not from when your Part B begins. Chapter 5 of Toni’s Medicare Survival Guide Advanced edition explains Medicare Part D and how to avoid Part D penalties.

Remember, with Medicare it’s what you don’t know that WILL hurt you! Toni’s new course, a downloadable video series called the “Confused about Medicare Workshop” and the “Medicare Survival Guide Advanced” edition are available at www.tonisays.com! Email info@tonisays.com or call 832/519-8664 with any questions.

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Dear Toni,

I turn 65 in April, am covered under my wife’s employer’s health insurance and am fighting liver cancer. I am participating in a clinical trial for a cancer medication which costs over $12,000 per month and am paying $0 for a medication that is curing my cancer.

I am concerned about what to do when I enroll in Medicare and if I will be in Medicare’s “donut hole” since this is a clinical trial. I am not planning on enrolling in Medicare until my wife, Sarah, retires when she turns 65 in 2 years.

Are clinical trial prescriptions covered under Medicare’s drug plans? What are my options?

Thanks!   Lee from Jackson, Miss.

Hello Lee:

What a smart decision you made to stay on Sarah’s employer benefits, because both you and Sarah can enroll in Medicare Parts A and B when she retires in 2 years at 65. At that time, you will be eligible for a Special Enrollment Period (SEP), avoiding the famous Medicare Part B penalty, and will be able to enroll in a Medicare Part D prescription drug plan. She will be enrolling in Medicare during her Initial Enrollment Period (IEP).

I have good news for you!  Medicare’s “donut hole” went away in 2025, and now  there is a specific drug plan maximum out of pocket every year.

Lee, Medicare’s Part D maximum out of pocket for 2026 which is $2,100, and you would qualify for that when you order the cancer drug costing over $12,000 per month if that prescription is in the formulary for the Medicare Part D plan you enroll in when you are no longer covered by Sarah’s employer health insurance. If that specific cancer drug is not approved for clinical trial and not covered by the Part D plan you enroll in, then you may have to pay the $12,000 per month.

Enroll in the Medicare Part D plan that covers all of your prescriptions, even though the most expensive prescriptions are those covered by a clinical trial program and currently costs you nothing. There may be a time when those expensive prescriptions are no longer covered by the clinical trial, and without the right plan you will experience paying that year’s Part D maximum out of pocket. Each year, Medicare changes the Part D prescription drug deductible, copays, and maximum out of pocket.

Whether your Part D prescription drug plan will pay for a medication used in a clinical trial depends on whether it is covered in the plan’s formulary or can be classified as a highest-tier  prescription  drug, which costs more. Then you will go into that year’s Medicare Part D’s maximum out of pocket.

*Beware: If you are not enrolled in a Part D plan that covers the expensive clinical trial prescriptions, then you will pay 100% out of your pocket for the expensive prescriptions that are not covered when the clinical trial ends.*

For those enrolled in a Medicare Advantage plan seeking clinical trial, page 35 of the 2026 Medicare & You handbook under “Clinical Research Studies” states, “If you’re in a Medicare Advantage plan, Original Medicare may cover some costs along with your Medicare Advantage plans. Contact your plan for details about coverage for Clinical Research Studies.  This short section also explains how different types of medical care are covered under Medicare Parts A and B.

Lee, enrolling in Medicare Part B when your wife retires is a good option. Both you and Sarah will qualify for a Medicare Supplement/Medigap Plan during your 6-month Medigap Open Enrollment Period without having to answer one health question. This period starts the month your Medicare Part B is effective.

Take your time and research which Medicare options meet your needs because with Medicare what you don’t know WILL hurt you! Exploring Medicare Part D and prescription drugs is one of the most important topics during a Toni Says Medicare consultation.

Email info@tonisays.com or call 832-519-8664 with your Medicare question or to schedule a Medicare consultation.  Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

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Hello Toni:       

In the new Medicare & You Handbook that I received about a month ago, I cannot find what the 2026 Medicare costs and premiums will be. I would like to know this information because I have been diagnosed with a heart condition and will need to undergo a heart surgery next year. I have looked online and cannot find the costs there either.

Do you have any idea what the 2026 Medicare costs will be?

Carol from Sugar Land, Texas

Hello Carol:

Every year the Medicare & You Handbook is mailed out before October 1to all Medicare beneficiaries to help guide them through the Medicare Open Enrollment Period (OEP) period which ends December 7. This year’s handbook states that at the time of printing, the premiums, and deductible amounts for Medicare Part A, Part B and Part D were not available.

The Centers for Medicare and Medicaid Services (CMS) released the 2026 Medicare costs last Friday, November 14, with an increase for both Medicare Parts A and B premiums and deductibles.

Below are the 2026 Medicare Part A and B premiums and deductibles, as well as information on the 2026 Medicare Part D changes that affect Medicare’s Part D prescription drug costs.

2026 Medicare Parts A and B premiums and costs:      

• Part A Costs (Inpatient Hospital): The new 2026 Part A inpatient hospital deductible will be an increase of $60, from $1,676 in 2025 to $1,736, for 2026. The Part A deductible starts over every 60 days. It is not a once-a-year deductible but  six times a year. Skilled Nursing is included under Part A, and the 2026 costs will be $0 copay per day for days 1-20 and $217.00 per day for days 21-100.
• Part B Costs (Medical): The new 2026 Part B medical/doctor deductible will increase by $26 from the $257 deductible in 2025 to $283 beginning Jan. 1, 2026. After the deductible is met, Medicare pays 80% of the Medicare-approved amount and the Medicare beneficiary pays the remaining 20% of the Medicare-approved amount.
• Part B Premium: The premium for 2026 has an increase of $17.90 from $185 in 2025 to $202.90 beginning Jan.1, 2026. Those with an income higher than $109,000 as an individual or $218,000 as a married couple will pay more for their Medicare Part B premium beginning Jan. 1, 2026. The premiums for higher income earners were also released on Nov.14 and can be viewed at www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles.

2026 Medicare Part D costs and co-pays:

• Initial Deductible: will increase by $25 from $590 in 2025 to $615 beginning Jan.1,2026.
• Initial Coverage: has 6 drug-tier stages; the Part D plan pays its share of the cost of your drugs, and you pay your share until the maximum amount of $2,100 out-of-pocket is met. Then you move into the Catastrophic Coverage stage and pay $0.
• Total Out-of-Pocket: Effective Jan. 1,2026, the maximum out-of-pocket will be $2,100.

Jan. 1 of each year, the Part D process starts all over again with a new Medicare Prescription Drug plan and a new initial deductible and maximum initial coverage limit.

Medicare’s Prescription Payment Plan, which began Jan. 1,2025, is a payment option available to help manage the $2,100 maximum out-of-pocket drug costs by spreading your monthly prescription drug costs throughout the year from January to December. For more information about the payment plan, visit www.medicare.gov or call your Medicare Part D plan.

Readers, your prescription drug needs can change with each yearly Medicare Open Enrollment Period. Chapters 5 and 6 of Toni’s Medicare Survival Guide Advanced edition explains Medicare Part D and Medicare Open Enrollment Period in “easy to understand” terms.

Review your Medicare options carefully, because with Medicare, what you don’t know WILL hurt you!  Have a Medicare question, email info@tonisays.com or call 832-519-8664. Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

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Hello, Toni:

You helped me sign up for a Medicare Supplement Plan G and a Medicare Part D prescription drug plan; both plans started January 2021. These two plans have served me well so far.

I just received information that my current Part D plan will no longer cover the Humira that I take twice a month as an injection for Crohn’s disease. I have looked at other 2026 Medicare Part D plans on the Medicare.gov site and discovered that there is not one Medicare Part D plan that is covering Humira.

Toni, do you know of another Part D provider you can sign me up for that will cover some or all of the costs for Humira?

Any recommendations you can make will be highly appreciated. Thanks, Toni

—-Gene from Sugar Land, Texas

Gene:

I do not have good news about Humira, this important prescription for your Crohn’s. You’re right, Gene. I also searched the Medicare.gov site for Humira without finding a stand-alone Medicare Part D plan that covered it. I saw that on the Medicare.gov site the total cost beginning January 1, 2026, for all 12 months for Humira will be $99,691.68, or $8,307.64 per month.

I did research on Google about “Why is Medicare was not covering Humira for 2026?.” with AI giving this answer. “Medicare Part D plans are not covering Humira in their 2026 formularies because they are increasingly switching to cheaper Humira biosimilars.” AI also said, “While some plans are removing the brand-name drug, they are still providing coverage for the drug class through its biosimilars to help reduce drug spending.”

I have never seen the word biosimilar associated with Medicare Part D prescriptions since Medicare Part D began January 1, 2006, so I also googled “biosimilar prescriptions.” Biosimilar prescriptions are explained as “lower-cost versions of expensive biologic drugs, under Medicare Part B and Part D.” Gene, other prescriptions that are similar to Humira and are less expensive may be covered and are what you might want to change to.

What I would suggest that you do, Gene, is call the physician that has prescribed you Humira and ask what alternatives prescriptions you can be changed to. Also, contact AbbVie, the manufacturer of Humira, at 1-800-222-6885 and ask if you qualify to receive any type of prescription drug assistance or visit the www.AbbVie.com website for more information.

This Medicare Open Enrollment has been the most stressful fall Medicare OEP that I have ever experienced since Open Enrollment began. It is extremely important that the 69 million Americans who are on Medicare visit www.medicare.gov to verify that ALL of their prescriptions are covered whether they have a stand-alone Medicare Part D plan or a Medicare Advantage HMO/PPO plan with a Prescription Drug plan included. (On Thursday, Nov. 20, at 4 p.m. CST, Toni will host a “Confused about Medicare” Zoom online workshop explaining enrolling in Medicare  Part D. Visit www.tonisays.com to register.)

Below are the 2026 Medicare Prescription Drug Costs and maximum-out-of-pocket:

• Initial deductible is $615.
• Initial Coverage Stage: During the initial coverage period with the six drug tiers, the Part D plan pays its share of the cost of your drugs, and you pay your share of the cost until the maximum amount of $2,100 out-of-pocket is met. Then you move to the catastrophic coverage stage.
• Catastrophic coverage: There is a $0 out-of-pocket once a Medicare beneficiary enters the catastrophic coverage stage. Medicare will pick up all costs of the covered prescriptions whether brand-name or generic with a stand-alone Medicare Part D plan or a Medicare Advantage with a Part D plan included and you will pay $0.

Readers, your prescription drug needs can change every Medicare OEP. Review your options carefully, because with Medicare, what you don’t know WILL hurt you! Email info@tonisays.com with your Medicare questions.

Zoom Live… Confused about Medicare Workshop on Thursday Nov. 20 at 4:00pm CST to 6:00pm CST. RSVP here now to reserve a spot for you and your Medicare friends or call 832/519-8664. Have exciting Medicare questions for Toni to answer!!

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Toni:

Currently, I am on a stand-alone Part D plan with a Medicare Supplement plan G because of my serious health issues. Last week, I received information about the changes to the 2026 Medicare Part D plan I am currently enrolled in, and the premium is increasing by $50 per month from $44.80 to $94.80 beginning January 1. The Part D plan also informed me that two of my expensive prescriptions for my heart and rheumatoid arthritis issue will no longer be covered on this specific plan beginning January 2026.

Toni, please explain in easy-to-understand terms what I need to do to change to a Part D plan that will cover all of my prescriptions before Medicare’s Open Enrollment Period ends on December 7. I have read your articles for years and now I need your Medicare guidance.

—Tammy from Cypress, Texas

Tammy:

The 2026 Part D plans became available to the public at www.medicare.gov on Wednesday, October 1 and there are serious changes with Part D premiums increasing. Medicare.gov is where America can find which Medicare Part D plan is affordable and covers their current prescription drugs.

The good news is that Medicare negotiated directly with manufacturers for the price of certain expensive brand-name Part D drugs and the price change will be effective January 1 for Eliquis, Xarelto, Januvia, Jardiance, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and NovoLog/Fiasp (insulin aspart).

For 2026, Medicare Part D will have three main stages: deductible, initial coverage, and catastrophic coverage. Costs and maximum-out-of-pocket are as follows:

• Initial deductible is $615.
• 6 Drug Tiers of Initial Coverage are: Drug Tier 1: Preferred Generic Drugs; Drug Tier 2: Generic Drugs; Drug Tier 3: Preferred Brand Drugs; Drug Tier 4: Non-Preferred Drugs; Drug Tier 5: Specialty Drugs and, beginning January 1, 2026, Drug Tier 6: Select Care Drugs begins for the first time.
• Initial Coverage Stage: During the initial coverage period with the six drug-tiers, the Part D plan pays its share of the cost of your drugs, and you pay your share of the cost until the maximum amount of $2100 out-of-pocket is met. Then you move to the catastrophic coverage stage.
• Catastrophic coverage: There is a $0 out of pocket when a Medicare beneficiary enters the catastrophic coverage stage. Medicare will pick up all costs of the prescriptions whether brand name or generic with a stand-alone Medicare Part D plan or a Medicare Advantage with a Part D plan included and you will pay $0.
• On January 1 of each year, the process starts all over again with a new Medicare Prescription Drug plan and new initial deductible and maximum initial coverage limit that leads you to the catastrophic coverage stage.

The Medicare Prescription Payment Plan is a payment option which began January 1, 2025, to help manage your out-of-pocket drug costs by spreading your monthly prescription drug costs throughout the year from January to December. For more information about the payment plan, visit www.medicare.gov or call your Medicare Part D plan.

Toni Says Tips to help you find a Part D plan:

• Visit medicare.gov to view 2026 Medicare stand-alone Part D and Medicare Advantage with Part D plans attached. The website has a tool for helping you narrow your search for a new Medicare Prescription Drug plan.
• Talk to your primary care and specialty doctors about which brand name drugs can be changed to generics.
• Get samples from your doctor to help control costs.
• Search various prescription drug programs such as GoodRx, Single Care or Amazon for less expensive prescription drug costs. Wal-Mart, Kroger, HEB and Costco also have discount prescription drug plans.

Readers, your prescription drug needs can change with each yearly Medicare Open Enrollment Period. Review your options carefully, because with Medicare, what you don’t know WILL hurt you! Email info@tonisays.com with your Medicare questions.

Confused about Medicare Workshop is now “Live” Wednesday, Oct.29, 6:30PM at Integrity Bank 8584 Katy Fwy, 1^st. floor Conference Room, Houston, TX. 77024.  RSVP:832/519-8664 or visit www.tonisays.com to reserve a seat for you and your Medicare friends.

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Hello Toni:

When I turned 65 in May 2024, I continued to work full-time with a health savings account HSA as my employer benefits and use GoodRX to cover prescriptions. My employer’s human resources manager advised me to enroll in Medicare Part A when I turned 65, which was not correct information because I could not fund my HSA from the time I enrolled in Medicare Part A. When I retire at 70 is when I will enroll in Medicare Part B.

Now I am experiencing a Medicare issue and need guidance, Toni. In July, I applied on medicare.gov for a Medicare Part D plan to begin Aug. 1 because I am now taking an expensive blood pressure prescription that GoodRX does not cover which costs over $650 a month.

I just received a notice from Medicare saying they do not have a record of me having prescription drug coverage that “met Medicare’s minimum standards” from 5/1/2024 to 7/31/2025, and I will receive a Part D late enrollment penalty. What does this mean?

Toni…Thank you in advance,

Don from Charlotte, NC

Don:

I do not have good news for you. You have a Medicare Part D prescription drug penalty problem because you did not enroll in a Medicare Part D plan at the right time when your Part A began 5/1/2024. Unfortunately, prescription discount programs — such as GoodRx, Single Care, AmazonRX or store prescription memberships such as Walmart, Kroger, etc., are not considered “creditable” coverage which is why you will be receiving Medicare’s late enrollment penalty (LEP).

The Medicare & You handbook states: Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, or individual health insurance coverage. If you go 63 days or more in a row without Medicare drug coverage or other creditable prescription drug coverage, you may have to pay a penalty if you sign up for Medicare drug coverage later.

So, Americans with “creditable” coverage can apply for a Medicare Part D plan at a later date without paying a penalty. (Chapter 5 of the Medicare Survival Guide Advanced edition explains Medicare Part D and how to avoid Part D penalties).

The Late Enrollment Penalty (LEP) when applying for Medicare Part D can be applied if:

— You are older than 65, retiring and leaving employer benefits and waited more than 63 days without creditable prescription drug coverage to enroll in Part D. (Filing Medicare forms with Social Security does not inform Medicare that you had creditable prescription drug coverage. Do not wait to enroll in a Part D plan.)

–Your prescription drug benefit (not health benefits) is not creditable as Medicare defines it.

–You never enrolled in Medicare Part D when first eligible for Medicare.

Medicare calculates the Part D penalty by multiplying 1% of the “national base beneficiary premium” ($36.78 in 2025) by the number of full, uncovered months you didn’t have either Part D or creditable coverage and rounding to the nearest 10 cents. That amount is added to your monthly Part D premium.

Your late enrollment period (LEP) does not begin from the day you lose or leave your company health plan, but from the month your Medicare Part A started. So, Don, your 14 months without creditable coverage will cost you an extra $5.15 per month plus the Part D premium for 2025. The national base amount can change each year, so your penalty will change and NEVER go away.

Remember with Medicare what you don’t know that WILL hurt you!  Please enroll in Medicare Part D whether you are taking prescriptions or not.

__________

Toni King is an author and columnist on Medicare, Social Security, and long-term care issues. She has spent nearly 30 years as a top sales leader in the field. If you have a Medicare question, email info@tonisays.com or call 832-519-8664. Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

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