Posted on Friday, 31st October 2025 by

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This guide is worth the time and effort to review and learn about your exceptional Medicare benefits. From signing up, what Medicare covers, the various plan options to consider, and how to get help paying for your healthcare drug costs, to your rights and protections.

Every year, Medicare sends out its “Medicare & You” pamphlet to anyone on Medicare or approaching age 65. Many throw out the previous year’s edition and replace it with the new one. Actually, there is much to discover with each edition, especially as we age and require more services.

The booklet you receive is tailored to your state or territory, in my case, Pennsylvania. Coverage changes and enhancements are covered at the very beginning on page 2 with a Table of Contents on page 3, followed by an extensive Index of Topics on pages 4 through 8.

For those who haven’t received a copy you can download a PDF version.




2026 Changes

If you are covered under a Part D prescription drug plan, your yearly out-of-pocket costs will be capped at $2,100. Once you reach this limit, Medicare pays all drug copayments and coinsurance for the remainder of the year. Another helpful option will be the ability to spread your drug costs across monthly payments throughout the year if needed.

The Part D maximum deductible for Medicare Part D plans will rise to $615 in 2026, an increase of $25 from the previous year. Beneficiaries will be responsible for all out-of-pocket costs until they meet the deductible.

Medicare is expanding its efforts to negotiate drug prices, resulting in lower costs for certain high-cost medications. Additionally, drug manufacturers will be responsible for covering these additional expenses, which will reduce prices at the pharmacy.

All adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) will be covered under Part D with no deductible or cost-sharing, enhancing access to preventive care.

Postal Service employees, retirees, and their families will get coverage through the new PSHB program. Twenty percent of the original FEHB enrollees transitioned to this new system during the last open season. Postal employees who retire on or after January 1, 2025, and are under 64, are required to enroll in Medicare Part B when they become entitled to Medicare Part A (typically at age 65) to remain enrolled in a PSHB plan.

Traditional Medicare is implementing prior authorizations in six states in 2026, including:

  • New Jersey
  • Ohio
  • Oklahoma
  • Texas
  • Arizona
  • Washington

This initiative is designed to reduce wasteful spending and to find ways to provide improved and expedited prior authorization processes. Unnecessary and or inappropriate care should be minimized through this effort.

The Long & Short of It

This guide is a wealth of information, easy to read and follow. Before signing up for Medicare, most people are unaware of the differences between Original Medicare, Medicare Advantage (MA), and Medicare Supplement Insurance (Medigap). This guide explains the differences in detail.

It isn’t only for those just signing up for coverage; many change from Original Medicare to Medicare Advantage or Supplement plans to reduce costs and/or improve coverage. Others, after making a change, end up moving back to Original Medicare if the coverage and cost savings they thought they were getting don’t materialize. It’s a two-way street fraught with anxiety if not prepared.

The “At a Glance” section starting on page 11 compares Original Medicare (Parts A & B) to Medicare Advantage (Part C) side-by-side. It’s straightforward, to the point, and highlights the significant differences between the two. If you’re considering moving to an MA plan, this is definitely a must-read. Medicare Supplement plans are covered in Section 5.

Section 11 compares non-FEHB health and drug plans in your area. It starts on page 119 and includes over 50 pages, and this doesn’t include Medigap offerings in your state! They remind everyone at the beginning of this section that you can’t buy a Medigap policy while you’re in an MA plan.

Federal employees and annuitants who wish to remain in the FEHB or PSHB program must review the FEHB or PSHB plan brochures to determine the available MA and MPDP plans associated with the carriers.

Twists and Turns

Medicare asks for your help to protect our benefits from fraud and medical identity theft. They suggest checking each Medicare Summary Notice (MSN) you receive, and your receipts and statements, for errors or services you didn’t get.

This happened to me in 2023. Someone ordered men’s catheters using my account number, charging Medicare close to $3,000 a month. I reported the problem by calling the following numbers, and they issued me a new card.

If you think your Medicare Number has been used fraudulently, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048 (pages 105–106).

There are differences for those enrolled in one of the Federal Employees’ Health Benefits (FEHB) plans. For example, Section 6 in the guide covers Medicare drug coverage (Part D) and states, “you’ll likely pay a late enrollment penalty for Part D coverage if you join a plan later.”

This penalty is waived for MA plans offered by your FEHB and PSHB carriers, and it also applies when you opt for a Medicare Prescription Drug Plan (MPDP) option. You will be required to pay a Part D premium if your income exceeds a certain amount, as determined by the Income-Related Monthly Adjustment Amount (IRMAA). This also impacts Part B premiums, which are income-adjusted as well.

When you sign up for an FEHB MA plan, you MUST stay enrolled in your FEHB plan. Most, if not all, of the FEHB MA plans have a zero premium; you are only responsible for the FEHB plan premium. These plans often offer a partial Part B premium reimbursement for you and your spouse as well.  Compare FEHB plans to their partnered MA options to understand these differences better.

Don’t risk losing your FEHB coverage. If you are considering a Medicare Supplement plan, you can’t suspend your FEHB coverage, and you won’t be able to return to the FEHB program next open season. Medicare Supplement plans (Medigap) are only offered by private insurance companies.

Helpful Retirement Planning Tools

Disclaimer: The information provided may not cover all aspects of unique or special circumstances.  Federal regulations, medical procedures, investment information, and benefit details are subject to change. To ensure the accuracy of this information, contact relevant parties for assistance, including OPM’s retirement center. Over time, various dynamic economic factors relied upon as a basis for this article may change.

The information contained herein may not be suitable for your situation. This service is not affiliated with OPM or any federal entity. You should consult a financial, medical, or human resource professional where appropriate. Neither the publisher nor the author shall be liable for any loss or other commercial damages, including but not limited to special, incidental, consequential, or other damages.

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Posted in ANNUITIES / ELIGIBILITY, BENEFITS / INSURANCE, ESTATE PLANNING, FINANCE / TIP, SOCIAL SECURITY / MEDICARE, SURVIVOR INFORMATION, WELLNESS / HEALTH | Comments (4)


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4 Responses to “Medicare & You 2026 – Significant Changes on the Way”

  1. linda chen Says:
    November 1st, 2025 at 11:36 pm

    hi, Dennis:

    please let us know if you continue with GEHA basic or Medicare Advantage?

    with such high premiums for 2026, I wonder if we’d take Medicare Part B together with FEHB, which is optional (I understand with the combo, you get near 100% coverred).

    thanks

  2. RK Dakon Says:
    November 2nd, 2025 at 8:03 pm

    I can’t get a straight answer out of GEHA about the SilverScript part d program, if they are going to re-enroll us and we have to opt out again, or since we opted out for the 2025 plan we won’t be opted back in for 2026.
    I have messaged GEHA and they are saying that we will be automatically opted back in, and more details to come.
    I have used the GEHA chat message and on chat a rep stated that if we opted out in 25 that we won’t be automatically opted in for silverscript in 26
    here is the message from them
    We have received your inquiry regarding your 2026 prescription plan enrollment

    The automatic opt in is a decision made in good faith by GEHA to help Medicare eligible retirees have access to affordable medication. If you are covered by Medicare and Medicare Part A or B or Parts A and B is primary and you are not enrolled in any Medicare Advantage Plan or any other Medicare plan, we will automatically enroll you in our SilverScript Employer Prescription Drug Plan (PDP) under Medicare Part D to prevent you from getting a penalty from Medicare for having no prescription coverage.

    You will still have the option to opt out after the first of any month and the changes will not be effective until the first of the following month. You have two options for opting out. You may get in contact with SilverScript by phone at 833-250-3241.You may also submit your request by submitting the disenrollment form when it becomes available for the 2026 plan year. More information will be provided on this as we get closer to the Open Season which begins on November 10.

    If you have additional questions or concerns, you can securely reply to this message, use our chat support, or speak to a customer care representative between 7 AM to 7 PM CST by calling the number listed on your member ID card.

    How are we going to find out for sure what they are going to do this year? Any hints? Thank you

  3. Dennis Damp Says:
    November 6th, 2025 at 1:44 pm

    I went through this last year, after you opt out once, as long as you don’t change plans, you will not have to do it each year. You can opt back in to SilverScript at a later date if desired. It took me serval months last year to have them remove SilverScript (Part D Coverage) and return me to GEHA’s prescription drug plan.

  4. Dennis Damp Says:
    November 6th, 2025 at 1:58 pm

    Linda, I’ve had GEHA Standard for over 12 years. The Standard plan premium for Self + 1 is still one of the lowest cost plans available, $404.11 per month for 2026, and provides comprehensive coverage. My wife and I remained in Traditional Medicare A & B and since turning 65 and we have had no out-of-pocket costs except for prescription drugs. Here is a link to an article I wrote for another service that compares GEHA Standard to their Medicare Advantage option that you will find helpful. The MA plan can be cost effective and reduce your costs. Plus, it does provide some unique benefits such as a Part B subsidy. Wheater or not you go with the Standard GEHA Plan, or their Medicare Advantage option depends on the issues I mention in the article. Here is another article I wrote that goes into even more details about the offered Medicare Advantage plans that you will find helpful as well.

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