Reference
Medicare answers
Each page here answers one question, completely, in the first sentence — then shows the numbers and names the dated source behind every one. No windup, no pitch. For the fuller discussions, see Medicare 101, the South Dakota Medigap guide, and the blog.
Last updated: August 21, 2026
Medicare & Medigap Basics
How Medicare Advantage and Medigap actually differ, what the lettered plans pay, and the enrollment rules — including the ones specific to South Dakota — with the 2026 dollar amounts and their CMS sources.
- Can you switch from Medicare Advantage back to Original Medicare and Medigap? Yes, you can drop Medicare Advantage and return to Original Medicare during the Annual Enrollment Period (Oct 15–Dec 7) or the MA Open Enrollment Period (Jan 1–Mar 31). But in South Dakota the Medigap half is guaranteed only with a federal right such as the 12-month trial right; otherwise carriers can underwrite.
- Does South Dakota have a Medigap birthday rule? No. South Dakota has no birthday or anniversary switching rule. It appears on no current state list (verified July 2026 guides). Outside your one-time 6-month open enrollment window or a federal guaranteed-issue event, switching Medigap plans in South Dakota generally requires medical underwriting.
- What does Medigap Plan G cover? Plan G covers every gap in Original Medicare that Medigap is allowed to cover except the annual Part B deductible ($283 in 2026), including the $1,736 Part A hospital deductible, hospital and medical coinsurance, skilled-nursing coinsurance, Part B excess charges, the first 3 pints of blood, and 80% of foreign travel emergencies.
- What is the difference between Medicare Advantage and Medigap? Medicare Advantage replaces how you receive Medicare (a private plan with its own network, drug coverage, and out-of-pocket cap), while Medigap supplements Original Medicare, paying its deductibles and coinsurance so you can see any provider that accepts Medicare. You cannot use both at once.
- What is the high-deductible Plan G deductible for 2026? $2,950 for calendar year 2026, set by CMS in October 2025, a 2.92% CPI-U increase over 2025's $2,870. The same deductible applies to high-deductible Plans F and J. You pay Medicare cost sharing up to that amount each year before the plan pays.
- When can you enroll in Medigap in South Dakota? Any time, but South Dakota insurers must accept you only during your one-time 6-month Medigap open enrollment period, which starts the first month you are both 65 or older and enrolled in Part B, or when a federal guaranteed-issue right applies. South Dakota also guarantees under-65 beneficiaries access to every plan.
American Indians & Medicare
How Medicare works alongside the Indian Health Service and tribal health programs: Part D creditable coverage, Purchased/Referred Care, what is (and is not) a Medicare rule, and where to get free help. Companion guide: American Indians and Medicare in South Dakota.
- Are there special Medicare enrollment rules for American Indians? No. Medicare has no American Indian or Alaska Native Special Enrollment Period and no AI/AN-specific enrollment window. The well-known monthly enrollment rule for members of federally recognized tribes is a Health Insurance Marketplace (ACA) rule, not a Medicare rule. Standard Medicare windows apply.
- Do American Indians pay Medicare costs at IHS or tribal facilities? No, at an IHS or tribal facility you will not be billed Medicare's deductible or coinsurance, but that is because the facility waives them (per the CMS Claims Processing Manual), not because Medicare exempts you. Outside the I/T/U system, normal Medicare cost sharing applies.
- Do I need Medicare if I have IHS coverage? Yes, enrolling in Medicare when you become eligible still matters, because IHS is not insurance: IHS says so itself, federal law makes Indian health programs the payer of last resort, and the Indian Health Manual can require denial of Purchased/Referred Care for someone who refuses to apply for Medicare.
- Does IHS count as creditable drug coverage for Medicare Part D? Yes. Federal regulation 42 C.F.R. § 423.56(b)(9) names coverage from the Indian Health Service, a Tribe or Tribal organization, or an Urban Indian organization as creditable prescription drug coverage, and Medicare.gov lists the Indian Health Service by name, so no Part D late penalty accrues while you have it.
- What is Purchased/Referred Care and how does Medicare affect it? Purchased/Referred Care (PRC) is the IHS program that pays outside, non-IHS providers for care a local facility cannot deliver, and Medicare affects it directly: IHS names Medicare as an alternate resource you are required to apply for, and refusing can require denial of PRC eligibility.
- Where can American Indians in South Dakota get free Medicare help? Start with the benefits coordinator at your IHS or tribal health facility and with SHIINE, South Dakota's free State Health Insurance Assistance Program (1-800-536-8197). Both are free and sell nothing. The IHS Great Plains Area office in Aberdeen serves all of South Dakota.
Prescription Costs & Part D
How Medicare prices a prescription in 2026: the $615 deductible ceiling, the $2,100 out-of-pocket cap that replaced the donut hole, drug tiers, pharmacy networks, and the rules that decide whether a drug is covered at all.
- Are vaccines free under Medicare? Adult vaccines recommended by the CDC's advisory committee and covered under Part D, including shingles and the Tdap booster, cost you $0 with no deductible. Flu, pneumococcal, COVID-19, and hepatitis B vaccines are covered under Part B, also at no cost when you use a provider who accepts assignment.
- Does Medicare Advantage include drug coverage? Most Medicare Advantage plans include Part D drug coverage and are labeled MA-PD, but not all do. Plans without it exist, and if you join one you generally cannot add a separate Part D plan, which can leave you exposed to a permanent late enrollment penalty.
- What are Part D drug tiers? Tiers are the cost groups a Part D plan sorts its covered drugs into, usually five of them, running from preferred generics at the bottom to specialty drugs at the top. Your cost for a drug is set by which tier that particular plan puts it on, not by the drug itself.
- What drugs does Medicare Part D not cover? Federal law excludes several categories from Part D entirely, including drugs for weight loss or weight gain, fertility drugs, cosmetic drugs such as those for hair growth, over-the-counter drugs, and most drugs for erectile dysfunction. Beyond those exclusions, each plan also has its own formulary.
- What happened to the Medicare donut hole? The coverage gap known as the donut hole was eliminated starting in 2025. Part D now has three phases instead of four: you pay your deductible, then a share of your drug costs, then nothing once your out-of-pocket spending reaches the annual cap, which is $2,100 in 2026.
- What is prior authorization for Medicare drugs? Prior authorization means your plan will not cover a drug until your prescriber justifies it in advance. Step therapy is a related rule requiring you to try a lower-cost drug first. Both are legal coverage restrictions, and both can be appealed, often quickly.
- What is the difference between a preferred and standard pharmacy? Both are in your plan's network and both will fill your prescription, but a preferred pharmacy has agreed to lower cost sharing with your plan, so the same drug on the same day can cost you less there. Standard network pharmacies cost more; out-of-network pharmacies may not be covered at all.
- What is the difference between Part B and Part D drugs? Part D covers prescriptions you pick up at a pharmacy and take yourself. Part B covers drugs administered to you by a professional, such as infusions and injections given in a clinic, plus a few specific categories. The distinction decides your cost, because Part B and Part D price drugs completely differently.
- What is the Medicare drug cost cap in 2026? In 2026 you will not pay more than $2,100 out of pocket for covered prescription drugs under Medicare Part D. Once your spending reaches that threshold, you pay nothing for covered drugs for the rest of the calendar year. This cap did not exist before 2025.
- What is the Medicare Part D deductible in 2026? No Medicare drug plan can charge more than $615 as its annual Part D deductible in 2026. That is a federal ceiling, not a set price: many plans charge less, some charge nothing, and a good number waive the deductible on their lowest generic tiers while applying it to brands.
- What is the Medicare Prescription Payment Plan? It is a free option that lets you spread your out-of-pocket Part D drug costs across monthly payments over the calendar year instead of paying at the pharmacy counter. It does not lower what you pay in total; it changes when you pay it, with no interest and no fees.
- What is the Part D late enrollment penalty? A permanent surcharge added to your Part D premium if you went 63 days or more without creditable drug coverage after becoming eligible. It equals 1% of the national base beneficiary premium, $38.99 in 2026, for each full month you went without, and you pay it for as long as you have Part D.
- When will I hit the $2,100 Medicare drug cap? It depends entirely on what your drugs cost. Someone on a single expensive brand-name drug can reach the $2,100 cap in the first few months of the year, while someone taking only common generics may never reach it at all, because a year of those drugs can total less than $100.
- Why did my prescription price change at the pharmacy? Almost always because you moved between Part D coverage phases. You pay full price during the deductible, a share of the cost during initial coverage, and nothing after your out-of-pocket total reaches $2,100. The drug did not change price; your phase did.
What Your Prescriptions Cost
What specific drugs cost under Medicare, using CMS spending data and the negotiated 2026 prices. Each page separates what the drug costs from what you pay, and shows the shape of a full year.
- Does Medicare cover weight loss drugs? No. Federal law excludes drugs used for weight loss from Medicare Part D coverage entirely, and no plan can cover them under its basic benefit. The same molecule can be covered when prescribed for a different, covered condition such as type 2 diabetes.
- How much do generic drugs cost with Medicare? Very little. Medicare Part D spent an average of $10.75 per claim on atorvastatin and $8.93 per claim on metformin in 2025, the two most widely used generics in the program. A full year of a common generic often costs less than a single month of a brand-name drug.
- How much does Eliquis cost with Medicare in 2026? Eliquis has a Medicare-negotiated price of $231 for a 30-day supply starting January 1, 2026, down from a $521 list price, a 56% cut. What you personally pay is a share of that lower price, running through your deductible and cost sharing until your out-of-pocket total reaches $2,100.
- How much does Enbrel cost with Medicare in 2026? Enbrel has a Medicare-negotiated price of $2,355 for a 30-day supply starting January 1, 2026, down from a $7,106 list price, a 67% cut. At that price you reach the $2,100 annual out-of-pocket cap within the first few months and pay nothing for covered drugs after that.
- How much does Entresto cost with Medicare in 2026? Entresto has a Medicare-negotiated price of $295 for a 30-day supply starting January 1, 2026, down from a $628 list price, a 53% cut. About 664,000 Medicare beneficiaries take it for heart failure.
- How much does Farxiga cost with Medicare in 2026? Farxiga has a Medicare-negotiated price of $178.50 for a 30-day supply starting January 1, 2026, down from a $556 list price, a 68% cut. Nearly a million Medicare beneficiaries take it for diabetes, heart failure, or chronic kidney disease.
- How much does Imbruvica cost with Medicare in 2026? Imbruvica has a Medicare-negotiated price of $9,319 for a 30-day supply starting January 1, 2026, down from a $14,934 list price. At that price the very first fill of the year carries you past the $2,100 out-of-pocket cap, after which covered drugs cost you nothing.
- How much does insulin cost with Medicare in 2026? No more than $35 for a one-month supply of each covered insulin product, with no deductible applied, at any in-network pharmacy. A three-month supply costs no more than $105. The cap applies to everyone with Part D drug coverage, including people who get Extra Help.
- How much does Januvia cost with Medicare in 2026? Januvia has a Medicare-negotiated price of $113 for a 30-day supply starting January 1, 2026, down from a $527 list price. At 79% off, it is the deepest discount of any drug in the first negotiation cycle.
- How much does Jardiance cost with Medicare in 2026? Jardiance has a Medicare-negotiated price of $197 for a 30-day supply starting January 1, 2026, down from a $573 list price, a 66% cut. Under the standard benefit that works out to roughly $1,050 out of pocket across a full year, below the $2,100 cap.
- How much does NovoLog cost with Medicare in 2026? You will not pay more than $35 for a one-month supply of NovoLog or Fiasp, because the federal insulin cap overrides ordinary cost sharing. Separately, the drug has a Medicare-negotiated price of $119 for a 30-day supply, down from a $495 list price.
- How much does Ozempic cost with Medicare in 2026? Ozempic is not one of the drugs with a negotiated price in 2026. Medicare Part D spent an average of $1,302.82 per Ozempic claim in 2025. At that cost, a member on the standard benefit reaches the $2,100 annual out-of-pocket cap around the sixth month and pays nothing after that.
- How much does Stelara cost with Medicare in 2026? Stelara has a Medicare-negotiated price of $4,695 for a 30-day supply starting January 1, 2026, down from a $13,836 list price, a 66% cut. A single fill costs more than twice the annual out-of-pocket cap, so you reach the $2,100 cap in the second month and pay nothing afterward.
- How much does Trulicity cost with Medicare in 2026? Trulicity has no negotiated Medicare price in 2026, and Part D spent an average of $1,295.09 per claim in 2025. It was selected in January 2026 for the third negotiation cycle, so a negotiated price takes effect for it on January 1, 2028.
- How much does Xarelto cost with Medicare in 2026? Xarelto has a Medicare-negotiated price of $197 for a 30-day supply starting January 1, 2026, down from a $517 list price, a 62% cut. Under the standard benefit that comes to roughly $1,050 out of pocket over a full year.
- Which costs less with Medicare, Eliquis or Xarelto? By negotiated price, Xarelto is slightly cheaper at $197 for a 30-day supply against Eliquis at $231, both effective January 1, 2026. In practice your plan's tier placement for each usually matters more than that $34 difference, and the two are not clinically interchangeable.
Medicare Drug Price Negotiation
The ten drugs Medicare negotiated prices for, effective January 1, 2026, what they now cost, why your own copay may not have moved, and which drugs are next.
- Did Eliquis get cheaper in 2026? Yes, substantially. Its negotiated price is $231 for a 30-day supply against a $521 list price, and CMS claims data shows average Part D spending per Eliquis prescription falling from $912.31 in 2025 to $399.01 in the first quarter of 2026.
- Do negotiated drug prices count toward the $2,100 cap? What you pay out of pocket for a negotiated drug counts toward the $2,100 cap exactly as it would for any other covered Part D drug. Because the drug now costs less, your spending accumulates toward the cap more slowly, which means a lower total for the year.
- Does drug price negotiation apply to Medicare Advantage? Yes. The negotiated maximum fair prices apply to drug coverage delivered through a Medicare Advantage plan with Part D benefits just as they do through a standalone Part D plan. What differs between plans is cost sharing and formulary placement, not the negotiated price.
- How much will negotiated drug prices save me? CMS projects about $1.5 billion in savings for people with Medicare drug coverage in 2026 across the whole program. Your individual savings depend on whether you take one of the ten drugs and whether your plan charges coinsurance, which falls with the price, or a flat copay, which usually does not.
- What is Medicare drug price negotiation? It is a program created by the Inflation Reduction Act of 2022 that lets Medicare directly negotiate prices for certain high-spending drugs that have no generic or biosimilar competition. The first ten negotiated prices took effect January 1, 2026.
- Which drugs are next for Medicare price negotiation? Fifteen more drugs have negotiated prices taking effect January 1, 2027. On January 27, 2026, CMS announced a further fifteen for January 1, 2028, including Trulicity, Biktarvy, Cosentyx, Xolair, and Botox, and this is the first cycle to include drugs covered under Part B.
- Which drugs have negotiated Medicare prices in 2026? Ten Part D drugs: Januvia, the NovoLog and Fiasp insulin family, Farxiga, Enbrel, Jardiance, Stelara, Xarelto, Eliquis, Entresto, and Imbruvica. Their negotiated prices took effect January 1, 2026, with discounts from 2023 list prices ranging from 38% to 79%.
- Why didn't my copay drop when negotiated prices started? Because a negotiated price sets what the drug costs, while your copay is set by your plan's cost sharing for the tier that drug sits on. If your plan charges a flat copay rather than a percentage, a lower drug price does not change your payment.
Extra Help & Paying Less
Extra Help, Medicare Savings Programs, QMB, and LI NET: who qualifies in 2026, what each one pays, how to apply, and an honest look at discount cards and manufacturer assistance.
- Can I change drug plans if I get Extra Help? Yes. If you have Medicaid or get Extra Help you may be able to change your Medicare drug coverage once per month, rather than being limited to the annual enrollment windows that apply to everyone else.
- Do drug discount cards work with Medicare? You can use a discount card, but not together with your Medicare drug plan on the same prescription, and anything you buy that way does not count toward your $2,100 out-of-pocket total. Discount cards are also not creditable drug coverage, so relying on one instead of Part D builds a permanent penalty.
- Do I get Extra Help automatically? You qualify automatically if you have full Medicaid coverage, if your state helps pay your Part B premium through a Medicare Savings Program, or if you receive Supplemental Security Income. Everyone else has to apply, and many people who would qualify never do.
- Do manufacturer assistance programs work with Medicare? Manufacturer copay coupons generally cannot be used with Medicare, because federal anti-kickback rules bar them for people in government drug programs. Manufacturer patient assistance foundations are different and often do serve Medicare beneficiaries, usually for drugs a plan does not cover.
- How do I apply for Extra Help? Apply through Social Security at ssa.gov or by calling 1-800-772-1213. The application is free, takes most people well under an hour, and you can apply for a Medicare Savings Program at the same time. In South Dakota, SHIINE will help you complete it at no cost.
- How do I lower my Medicare drug costs? Start with Extra Help, since it is the largest single reduction available and is badly underclaimed. Then check whether your drugs are on a lower tier under a different plan, ask about generics, price mail order, and use the Medicare Prescription Payment Plan if timing rather than total is the problem.
- What are Medicare Savings Programs in South Dakota? Medicare Savings Programs are state-administered programs that pay your Medicare premiums and, in the case of QMB, your deductibles and coinsurance too. In South Dakota you apply through the Department of Social Services, and qualifying also gets you Extra Help with drug costs automatically.
- What are the Extra Help income limits for 2026? In 2026 the limits are $23,940 in income and $18,090 in resources for an individual, and $32,460 in income and $36,100 in resources for a married couple living together. Alaska and Hawaii have higher income limits. Your home and vehicle do not count as resources.
- What do you pay for drugs with Extra Help in 2026? No more than $5.10 for each generic drug and $12.65 for each brand-name drug, with a $0 plan premium and $0 deductible. Once total drug costs reach $2,100 you pay nothing at all. If you also have full Medicaid and QMB, the cap is $4.90 per covered drug.
- What is Extra Help for Medicare drug costs? Extra Help is a federal program, also called the Part D Low Income Subsidy, that pays most of your Medicare drug costs if your income and resources are below set limits. In 2026 it means a $0 plan premium, a $0 deductible, and generics capped at $5.10 and brand-name drugs at $12.65.
- What is LI NET? LI NET, the Limited Income Newly Eligible Transition program, gives temporary Medicare Part D drug coverage to people who qualify for Extra Help or Medicaid but are not yet enrolled in a drug plan. It can also reimburse you for covered drugs you paid for after you qualified.
- What is QMB and what does it pay? QMB, the Qualified Medicare Beneficiary program, is the most comprehensive Medicare Savings Program. It pays your Part A and Part B premiums and your Medicare deductibles, coinsurance, and copays, and providers are prohibited from billing you for those amounts.
· Big Sioux Benefits Data Desk