Navigating Medicare - Rodney Shepherd

Presented by Rodney Shepard, Medicare Specialist
Informed Prostate Cancer Support Group Meeting - November 2025

Introduction

Navigating Medicare can feel overwhelming, especially when you're managing a prostate cancer diagnosis. At our recent support group meeting, Medicare expert Rodney Shepard provided a thorough overview of Medicare options, coverage rules, and critical decision points that every patient should understand. This article summarizes his presentation and incorporates the latest developments in Medicare policy to help you make informed decisions about your healthcare coverage.

Medicare Basics: Understanding the Parts

Medicare isn't a single program—it's actually divided into several parts that work together (or separately) to provide your healthcare coverage:

Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facilities, hospice care, and some home healthcare. If you've worked 40 quarters or more, you're entitled to Part A at no cost. For 2025, the Part A deductible is $1,716 for hospital stays, with additional daily charges after day 60.

Part B (Medical Insurance): Covers doctor visits, outpatient services, preventive care, and durable medical equipment (DME). For 2025, the standard monthly premium is $185, with expectations it will increase to approximately $187 in 2026. After meeting a $288 annual deductible, Medicare typically covers 80% of costs, leaving you responsible for the remaining 20%—with no cap on that 20%.

Part C (Medicare Advantage): These are comprehensive plans offered by private insurers that include your Part A, Part B, and usually Part D (prescription drugs) all in one package. They're often called "MAPD" plans (Medicare Advantage Prescription Drug plans).

Part D (Prescription Drug Coverage): Standalone prescription drug plans that work with Original Medicare or Medicare Supplement plans. For 2025, the maximum out-of-pocket cost is $2,100—a significant improvement over previous years thanks to the Inflation Reduction Act.

The Critical Decision: Medicare Advantage vs. Medicare Supplement

This is perhaps the most important choice you'll make, and timing matters tremendously.

Medicare Supplement (Medigap) Plans

Medicare Supplement plans fill the gaps left by Original Medicare, covering that 20% coinsurance and other out-of-pocket costs. The most popular is Plan G, which covers everything except the Part B deductible.

Advantages for prostate cancer patients:

No network restrictions: You can see any doctor in the United States who accepts Medicare—crucial if you want access to specialists at UCSD, City of Hope, UCLA, or other major cancer centers
No referrals needed: You control your care and can see specialists directly
Predictable costs: After your deductible, everything is typically covered 100%
Nationwide coverage: If you travel or want a second opinion across the country, you're covered

The catch: Monthly premiums average $230-$400 depending on your age and location, and these premiums increase annually.

The critical window: When you turn 65 and enroll in Part B, you have a six-month guaranteed issue period. During this time, insurance companies must accept you regardless of your health conditions—even if you've been diagnosed with cancer, had a stroke, or have any other pre-existing condition. After this window closes, Medigap plans are medically underwritten, meaning companies can (and often will) deny you coverage if you have prostate cancer or other serious conditions.

Medicare Advantage (Part C) Plans

Medicare Advantage plans are typically HMOs (Health Maintenance Organizations) that provide all-in-one coverage.

Advantages:

Usually zero monthly premium beyond your Part B premium
Includes prescription drug coverage
Often includes extra benefits like dental, vision, and gym memberships
Maximum out-of-pocket protection (typically $8,000 for in-network care)

Disadvantages for cancer patients:

Network restrictions: You must stay within your plan's network of doctors and hospitals
Referrals required: Your primary care physician controls access to specialists
Prior authorizations: Treatments may require committee approval, which can delay care
Limited geographic access: If you want to see specialists outside your network area, you'll pay 100% of costs

What About PPO Medicare Advantage Plans?

PPO (Preferred Provider Organization) plans offer more flexibility than HMOs, allowing both in-network and out-of-network care. However, these plans are rapidly disappearing from the market. As of 2026, many carriers have discontinued their PPO options due to the financial burden created by the Inflation Reduction Act's requirement that carriers cover 60% of all medication costs.

Important note: If your PPO plan is being discontinued, you qualify for guaranteed issue onto a Medicare Supplement plan without medical underwriting—even if you have cancer. This is one of the rare exceptions to the six-month window rule.

Special Situations That Grant Guaranteed Issue Rights

Beyond your initial six-month enrollment period, certain circumstances grant you guaranteed issue rights to enroll in a Medigap plan without medical underwriting:

Moving to a different county or state: This triggers a new enrollment period
Loss of employer coverage: When you retire and lose group health coverage
PPO plan discontinuation: If your Medicare Advantage PPO is being cancelled
Underwriting holidays: Blue Shield occasionally offers special enrollment periods (though none were offered in 2025)

Understanding Prescription Drug Coverage (Part D)

The Inflation Reduction Act brought significant improvements to Part D coverage in 2025:

Maximum out-of-pocket: $2,100 per year (a dramatic reduction from previous years)
After reaching the cap: All medications are covered at zero cost for the remainder of the year
Insulin cap: $35 per month for insulin products
Standard deductible: Up to $615 (though many plans have lower or zero deductibles)

How the 25% Rule Protects You

Medicare requires a 25% coinsurance on brand-name medications, but here's the key: even if you only pay a $50 copay on a $1,000 medication, the system applies the full 25% ($250) toward your $2,100 maximum. This means most patients never actually reach the $2,100 cap because the credited amounts exceed what they pay out of pocket.

Annual Plan Review is Critical

This is extremely important: Prescription drug formularies (the list of covered medications and their tier placements) can change at any time during the year, not just during the Annual Enrollment Period. Your medication that was tier 3 (lower cost) in January might become tier 5 (higher cost) in June, and you cannot change plans mid-year.

This is why Medicare experts like Rodney Shepard recommend reviewing your medications and plan options every single year during the Annual Enrollment Period (October 15 - December 7). Even a small change in your medication regimen could mean significant savings by switching to a different Part D plan.

Enrollment Periods: When You Can Make Changes

Understanding when you can enroll or change plans is crucial:

Initial Enrollment Period (IEP): Seven months total—three months before your 65th birthday, your birthday month, and three months after. Miss this window, and you'll face late enrollment penalties.

Annual Enrollment Period (AEP): October 15 - December 7 each year. You can make unlimited changes during this period; the last application you sign before December 7 is the one that takes effect January 1.

Open Enrollment Period (OEP): January 1 - March 31, but only for people already on Medicare Advantage plans. You can make one change during this period if you're unhappy with the plan you selected during AEP.

Special Enrollment Periods (SEP): Triggered by qualifying events like moving, losing other coverage, or developing chronic conditions that qualify for Special Needs Plans.

IRMAA: The "Medicare Means Test"

If your income exceeds certain thresholds, you'll pay Income-Related Monthly Adjustment Amounts (IRMAA) on top of your standard Part B and Part D premiums. For 2025, the threshold is approximately $103,000 for individuals. If you exceed this, you'll pay additional premiums based on your income level—another 20-30% penalty that compounds over time if you delayed enrollment.

The Late Enrollment Penalty Trap

Part B Penalty: If you go 63 days or more without creditable coverage after your Initial Enrollment Period, you'll pay a lifetime penalty of 1% of the national base premium for each month you delayed enrollment. This penalty never goes away.

Part D Penalty: Similarly structured—1% of the national base premium (about $34 in 2026) for each month without coverage. Also permanent.

The exception: These penalties don't apply if you have qualifying group health insurance through an employer (yours or your spouse's). Importantly, COBRA does not count as group coverage for this purpose.

Special Considerations for Prostate Cancer Patients

Choosing the Right Plan for Active Treatment

If you're newly diagnosed and anticipating surgery, radiation, or other intensive treatments:

Strong recommendation: Enroll in a Medicare Supplement Plan G during your guaranteed issue period. Here's why:

Access to top specialists: You can go to any cancer center in the country without network restrictions
No treatment delays: No prior authorizations or committee approvals for procedures
Predictable costs: After your Part B deductible ($288), you have zero out-of-pocket costs
Multi-state second opinions: If you want opinions from Johns Hopkins, MD Anderson, Mayo Clinic, and Sloan Kettering, you're covered

Active Surveillance Considerations

If you're on active surveillance with low-risk disease:

A Medicare Advantage plan might be appropriate during this phase since your care needs are minimal. However, remember that if your cancer progresses and you want to switch to a Medicare Supplement plan, you'll face medical underwriting and likely be denied if you already have a cancer diagnosis.

The "Birthday Rule" for Medigap Plans

California and several other states have a "birthday rule" that allows you to switch between Medigap plans during a 63-day window around your birthday without medical underwriting. However, there's a critical limitation: you can only move to a plan with equal or lesser benefits. If you start with Plan N (lower coverage) and want to move to Plan G (higher coverage) the next year, you'll face underwriting and likely be denied if you have cancer.

Strategy: Start with Plan G. You can always move down to Plan N if you want lower premiums, but you can rarely move back up.

Avoiding Medicare Scams

Medicare scams are rampant, especially during enrollment periods. Remember:

Medicare never calls you: If someone claims to be from Medicare on the phone, hang up
Social Security never calls you: Same rule applies
Protect your Medicare number: Treat it like a credit card number
Agents cannot initiate contact: Unless you've given written permission, licensed agents cannot call you unsolicited
Review your Medicare Summary Notices: Check for fraudulent charges

HSA Complications with Medicare

If you have a Health Savings Account (HSA) and enroll in Medicare Part A, you face a significant complication:

Once enrolled in Part A, you cannot contribute new money to your HSA (50% IRS penalty applies)
You can continue to use existing HSA funds for qualified medical expenses
If you're working past 65 with employer coverage, consider delaying Part A enrollment to maintain HSA contribution eligibility
Important: Once you begin receiving Social Security benefits, you're automatically enrolled in Part A, which ends your HSA contribution eligibility

Recent Medicare Policy Changes and Updates

The Inflation Reduction Act's Impact (2025)

The Inflation Reduction Act has fundamentally changed Part D coverage:

Eliminated the "donut hole" coverage gap
Established the $2,100 maximum out-of-pocket limit
Required insurers to cover 60% of all drug costs
Capped insulin at $35/month

However, these requirements have created financial pressure on insurance companies, leading many to discontinue PPO plans and reduce provider networks.

2026 Outlook

Based on current trends:

Part B premiums expected to increase to approximately $187/month
Continued consolidation of Medicare Advantage plans
Further reduction in PPO plan availability
Potential network changes at major health systems (including reports that UCSD may no longer accept certain Blue Shield HMO plans)

Federal Employee Health Benefits (FEHB) Considerations

If you're a federal employee or retiree with FEHB coverage:

You can keep your FEHB plan instead of enrolling in Medicare (though experts often recommend enrolling in both)
Critical warning: If you drop your FEHB coverage, you typically cannot get it back
One exception exists: some federal contracts specifically allow reinstatement, but this is rare
Carefully review your specific FEHB plan documents before making any changes

Veterans Administration (VA) Benefits

If you have VA healthcare:

You can opt out of Part B without penalty since VA coverage is considered creditable
This saves you the $185/month Part B premium
However, VA coverage may have geographic limitations
Consider your actual healthcare access and whether you use VA facilities regularly

Working Past 65: Special Rules

If you continue working past 65 with employer group health insurance:

You can delay Medicare enrollment without penalty
Your employer coverage must be through a group plan with 20+ employees
You get a Special Enrollment Period (8 months) after your employment or coverage ends
Start the enrollment process three months before retirement to ensure seamless coverage

The Bottom Line: Key Recommendations

Based on Rodney Shepard's expertise and current Medicare policy:

For newly diagnosed prostate cancer patients:

Enroll in Medicare Supplement Plan G during your six-month guaranteed issue window if you can afford the premiums ($230-$400/month)
Choose a separate Part D prescription drug plan
Review your Part D plan annually—formularies change constantly

For patients on active surveillance:

Consider starting with Plan G anyway—you can't predict when you'll need comprehensive access
If cost is prohibitive, Medicare Advantage may work, but understand you're likely locked out of Medigap plans later

For all patients:

Never miss your Initial Enrollment Period unless you have qualifying employer coverage
Review your coverage every year during the Annual Enrollment Period
Get professional help—Medicare agents like Rodney work at no cost to you (they're compensated by Medicare)
Use Medicare.gov to compare Part D plans based on your actual medications

For younger readers:

Start planning at age 64.5—don't wait until your 65th birthday
Understand that decisions made at 65 may be permanent if your health changes
When in doubt, choose broader access (Medigap) over lower premiums (Medicare Advantage)

Additional Resources

Medicare.gov: Official Medicare website for plan comparisons
State Health Insurance Assistance Program (SHIP): Free Medicare counseling
Social Security Administration: SSA.gov for enrollment
Extra Help/Low Income Subsidy: Application for prescription drug assistance

Conclusion

Medicare decisions are complex, but they're also critically important for prostate cancer patients who need access to specialized care. The six-month guaranteed issue window when you turn 65 may be your only opportunity to secure comprehensive, nationwide coverage through a Medicare Supplement plan. Once that window closes and you have a cancer diagnosis, you'll likely be locked into whatever coverage you have.

Don't rush this decision, but don't delay it either. Work with a licensed Medicare agent, review your options carefully, and choose the plan that best supports your healthcare needs—not just for today, but for the potentially long journey ahead. As multiple members of our support group demonstrated, many people live 10, 15, even 20+ years after their prostate cancer diagnosis. Make sure your Medicare coverage can support you for that entire journey.

Critical Medicare Issues for Our Members not discussed in the meeting.

SIDEBAR: Medicare Advantage and Advanced Prostate Cancer Treatment - A Growing Concern

The Promise vs. The Reality

When Medicare Advantage (Part C) plans were introduced, they were supposed to provide at least equivalent coverage to Original Medicare, often with additional benefits like dental and vision care. For prostate cancer patients, however, the reality has become increasingly problematic—particularly for those requiring advanced or specialized treatments.

The Prior Authorization Barrier

The most common complaint: Medicare Advantage plans require prior authorization for many advanced treatments that would be automatically covered under Original Medicare with a Medicare Supplement plan.

What This Means in Practice:

Scenario: Your oncologist at UCSD recommends Pluvicto (lutetium Lu 177 vipivotide tetraxetan), an advanced radiopharmaceutical for metastatic castration-resistant prostate cancer.

With Original Medicare + Medigap:

Doctor orders treatment
Treatment proceeds
Medicare pays 80%, Medigap covers the remaining 20%
No delays

With Medicare Advantage:

Doctor submits prior authorization request
Request goes to insurance company's medical review committee
Committee (often including doctors unfamiliar with your case) reviews
Approval can take days to weeks
Denial is possible, even for FDA-approved, guideline-recommended treatments
Appeals process can take additional weeks or months
Treatment delayed or denied while cancer progresses

Real Problems Our Members Report

1. Denial of Advanced Radiopharmaceuticals

Pluvicto (Lu-177-PSMA-617): Multiple members report Medicare Advantage plans denying or delaying this treatment, approved by FDA in 2022, despite meeting all clinical criteria. Reasons given:

"Experimental" (despite FDA approval)
"Not first-line treatment" (it's not meant to be)
"Requires step therapy" (forcing you to fail on cheaper treatments first)

Actinium-225 targeted therapy: Members seeking access to this promising treatment report automatic denials from MA plans, even when available through clinical trials or expanded access programs.

2. Specialist Access Restrictions

The network problem: Many Medicare Advantage plans in San Diego don't include—or severely limit access to—top prostate cancer specialists:

UCSD Moores Cancer Center
Some Scripps oncologists
Specialized urologic oncologists with PSMA PET imaging expertise

Result: You may need to:

Switch to an in-network doctor you didn't choose
Pay 100% out-of-pocket for out-of-network care
Travel to stay within network
Delay treatment while switching providers

3. Advanced Imaging Denials

PSMA PET scans: This game-changing imaging technology (FDA-approved Ga-68-PSMA-11 and Pylarify) faces routine denials from Medicare Advantage plans despite being:

More sensitive than conventional imaging
Recommended by NCCN guidelines
Covered by Original Medicare

Common denial reasons:

"Not medically necessary" (contradicting your oncologist's judgment)
"Conventional CT/bone scan adequate" (they're not)
"Requires prior authorization that takes weeks"

4. "Step Therapy" Requirements

Medicare Advantage plans increasingly require step therapy (also called "fail first" protocols):

Example: Before approving darolutamide (Nubeqa) or other newer AR pathway inhibitors, plans may require you to:

Try and fail on older, less effective medications
Document side effects or progression
Wait specified time periods
Repeat the authorization process

The problem: You're forced to wait for cancer to progress on inadequate treatment before accessing the therapy your doctor originally recommended.

5. Treatment Setting Restrictions

Some Medicare Advantage plans restrict where you can receive treatment:

May require you use specific infusion centers
May deny hospital-based treatment in favor of cheaper outpatient settings
May not contract with academic medical centers where clinical trials are available

Real impact: A member reported his MA plan denied Provenge treatment at UCSD, requiring him to travel to a contracted facility 50 miles away—despite active treatment at UCSD already in progress.

The Financial Incentive Problem

Why does this happen? Medicare Advantage plans are for-profit (or in some cases, non-profit but still budget-constrained) and receive a fixed payment per patient from Medicare. Every dollar they spend on your care reduces their profit margin.

The incentive structure:

Original Medicare: Fee-for-service (providers bill for services rendered)
Medicare Advantage: Capitated payment (fixed amount per patient)
Result: MA plans profit by denying or delaying expensive treatments

The Numbers Are Telling:

According to recent analyses:

Medicare Advantage plans deny approximately 15% of prior authorization requests that would have been automatically covered under Original Medicare
Appeals of denials succeed about 75% of the time—meaning many denials were inappropriate
Average time for prior authorization: 5-14 business days
Appeals can take 30-60 days or longer

For cancer patients, time matters. Every week of delay can mean disease progression.

The "Equivalent Coverage" Myth

Federal law requires Medicare Advantage plans to cover "at a minimum" what Original Medicare covers. However:

The loopholes:

Medical necessity determinations: Plans can claim treatments aren't "medically necessary" even when your doctor disagrees
Prior authorization: Creates barriers that don't exist in Original Medicare
Network restrictions: Limits where you can get covered care
Formulary limitations: Part D drug coverage can be more restrictive

Legal but harmful: These practices are technically legal under current Medicare regulations, but they create significant barriers to optimal cancer care.

What Prostate Cancer Patients Should Know

Red Flags with Medicare Advantage Plans:

⚠️ You're planning advanced treatment (Pluvicto, Actinium-225, new clinical trials)

⚠️ You want access to academic medical centers (UCSD, City of Hope, UCLA)

⚠️ You need cutting-edge imaging (PSMA PET scans)

⚠️ You want second opinions from out-of-network experts

⚠️ Your cancer is progressing and you need rapid treatment changes

⚠️ You're considering clinical trials (may require specific institutions)

When Medicare Advantage Might Work:

✓ Low-risk disease on active surveillance (minimal treatment needs)

✓ Completed initial treatment with stable PSA (routine monitoring only)

✓ Your preferred doctors are in-network and staying there

✓ Cost is a primary concern (you can't afford $200-400/month for Medigap)

✓ You're willing to fight denials and navigate bureaucracy

The Difficult Trade-off

The cruel irony: Medicare Advantage plans often attract patients with their zero premium, but those patients may face:

Thousands in unexpected out-of-pocket costs for denied treatments
Delays that allow cancer progression
Inability to access optimal care

Meanwhile, Medicare Supplement (Medigap) Plan G costs $230-400/month but provides:

Seamless access to any Medicare provider nationwide
No prior authorizations
Predictable costs (essentially zero after Part B deductible)
Freedom to seek care anywhere

For a prostate cancer patient facing years of treatment: The $2,760-4,800/year in Medigap premiums may be far less expensive than fighting MA plan denials and paying out-of-pocket for out-of-network care.

What You Can Do

If You're Already on Medicare Advantage:

Document everything: Keep records of denials, delays, and their impact on your health
Appeal immediately: Don't accept initial denials—appeal with your doctor's support
Contact your doctor's office: They often have staff dedicated to fighting insurance denials
Know your rights: You have the right to an expedited appeal for urgent situations
Consider switching during AEP: October 15-December 7 annually

If You're Approaching 65:

Seriously consider Medicare Supplement Plan G during your guaranteed issue period
Calculate the true cost: Factor in potential denials and out-of-network costs
Talk to prostate cancer patients who've navigated both systems
Remember: You likely cannot switch to Medigap later once you have a cancer diagnosis

Advocacy Needed:

Our support group believes Medicare Advantage plans should face:

Stricter enforcement of "equivalent coverage" requirements
Transparent reporting of denial rates and reasons
Time limits on prior authorization decisions (24-48 hours for oncology)
Penalties for inappropriate denials that delay cancer care
Expedited appeals for progressive, life-threatening diseases

The Bottom Line

Medicare Advantage can work for healthy retirees with minimal healthcare needs. But for prostate cancer patients—especially those with advanced disease—these plans often create barriers to optimal care that don't exist under Original Medicare with a Medigap plan.

The hard truth: The zero-premium Medicare Advantage plan that looks attractive at age 65 may become a nightmare when you're 72 and need Pluvicto or want a second opinion at Johns Hopkins.

If you're in that six-month guaranteed issue window after enrolling in Medicare Part B: Seriously consider starting with Medicare Supplement Plan G. You can always switch to Medicare Advantage later, but you cannot reliably switch back once you have a cancer diagnosis.

Have you experienced treatment denials or delays with Medicare Advantage? We want to hear your story. Contact the support group to share your experience and help us advocate for better policies. Your experience could help other patients make informed decisions.

For Medicare Advantage complaints:

Medicare: 1-800-MEDICARE (1-800-633-4227)
California Department of Managed Health Care: 1-888-466-2219
File complaint online at Medicare.gov

SIDEBAR: Medicare Advantage in San Diego County - What Prostate Cancer Patients Need to Know in 2026

The Dramatic Market Shift

San Diego County is experiencing an unprecedented upheaval in Medicare Advantage coverage that directly impacts prostate cancer patients' access to top-tier oncology care. Two major developments in 2024-2026 have fundamentally changed the landscape:

1. Scripps Health's Complete Exit (2024)

In January 2024, Scripps Clinic and Scripps Coastal medical groups dropped all Medicare Advantage plans, affecting approximately 32,000 San Diego patients. Scripps CEO Chris Van Gorder stated that "the revenue from Medicare Advantage plans is not sufficient to cover the cost of the patient care we provide," citing losses exceeding $75 million annually.

The impact on cancer patients was immediate and severe. One patient whose husband was undergoing cancer treatment at Scripps MD Anderson Cancer Center after receiving 28 radiation treatments was forced to find new oncologists, calling the change "disgusting" and questioning whether her husband would "be able to receive the excellent care that has kept him alive through three separate cancer battles". When asked if there were any exceptions for patients currently undergoing treatment for serious conditions such as cancer, Scripps CEO said no, stating "This is an insurance issue".

Current status: Scripps now accepts only Original Medicare with Medicare Supplement (Medigap) plans. No Medicare Advantage plans are accepted at Scripps Clinic or Scripps Coastal.

2. UCSD Health's Severe Network Restrictions (2025-2026)

Following Scripps' lead and dealing with an influx of nearly 50,000 Scripps patients who moved their care to UCSD, UC San Diego Health has dramatically restricted Medicare Advantage access:

Effective January 1, 2026:

DISCONTINUED PLANS (no longer accepted at UCSD):

Blue Shield Select Medicare Advantage PPO - discontinued in San Diego County
AARP United Healthcare Medicare Advantage PPO - discontinued in San Diego County
All Humana plans (Humana Gold Plus, Humana UC San Diego, Humana USAA Honor) - UCSD contract terminated

CRITICAL FINDING: There are currently no Medicare Advantage PPO plans offered in San Diego County that UC San Diego Health is in-network with.

SEVERELY LIMITED ACCESS:

SCAN Medicare Advantage HMO - specialty services only with referral and authorization, no new primary care access
SCAN Select HMO - primary care limited to UC San Diego Health Affiliated Groups: Perlman Clinic, One Medical, and other select providers
Blue Shield 65 Plus HMO - specialty services only with referral and authorization from their IPA and/or health plan

What This Means for Prostate Cancer Patients

UCSD Moores Cancer Center is San Diego's only NCI-designated Comprehensive Cancer Center. For prostate cancer patients, UCSD offers:

Advanced PSMA PET imaging
Clinical trials for Pluvicto and experimental treatments
Specialized radiation oncology (including SBRT, proton therapy)
Access to leading urologic oncologists
Multidisciplinary tumor boards

If you're on a Medicare Advantage plan and want access to UCSD Moores Cancer Center for prostate cancer treatment in 2026, your options are extremely limited:

SCAN HMO plans - But you can only see UCSD specialists (oncologists) with referrals and prior authorization. You cannot have a UCSD primary care doctor unless you use affiliated groups like Perlman Clinic or One Medical.
Blue Shield 65 Plus HMO - Similar restrictions: specialty only, requires referrals and authorization.
Switch to Original Medicare + Medicare Supplement Plan G - This provides full, unrestricted access to UCSD, but costs $230-400/month in premiums.

The San Diego County Medicare Advantage Landscape for 2026

According to current data:

Total plans available: 60 Medicare Advantage plan options in San Diego County for 2026, with 51 costing nothing beyond the Part B premium

Top 3 plans by enrollment:

Kaiser Permanente Senior Advantage San Diego (HMO) - 67,324 enrollees
UHC Sharp Medicare Advantage ValueRx CA-12P (HMO-POS) - 20,631 enrollees
SCAN Alta (HMO) - 16,246 enrollees

Star ratings: 46% of plans achieving 4 stars or better, 54% at 3 stars, 0% below 3 stars

Average maximum out-of-pocket: $3,312 (maximum allowed is $9,250 in 2026)

Specific Plan Considerations for Prostate Cancer Patients

Kaiser Permanente (Largest Enrollment)

Pros:

Integrated healthcare system with own hospitals and doctors
67,324 enrollees in San Diego - by far the largest plan
Coordinated care within Kaiser system
Zero or low monthly premiums

Cons:

Must use Kaiser facilities and doctors exclusively
Cannot access UCSD Moores Cancer Center
Cannot access Scripps
Limited to Kaiser's oncology services
Cannot get second opinions outside Kaiser network without paying 100% out-of-pocket

Bottom line for prostate cancer: Only viable if you're comfortable receiving all care within Kaiser's system. You cannot access San Diego's NCI-designated cancer center or participate in non-Kaiser clinical trials.

Sharp Medicare Advantage (Second Largest)

Pros:

Access to Sharp healthcare system
20,000+ enrollees
Established local provider

Cons:

HMO-POS restrictions
Cannot access UCSD Moores
Cannot access Scripps
Network limited to Sharp-affiliated providers

SCAN Plans (Third Largest)

Pros:

16,246 enrollees
Some access to UCSD (specialty only with restrictions)
Long-standing San Diego presence

Cons:

UCSD access is specialty-only with referrals and prior authorization required
No new primary care access at UCSD
Primary care limited to affiliated groups like Perlman Clinic or One Medical

Blue Shield Plans

Pros:

Some HMO options still accepted at UCSD (specialty only)
Wide network historically

Cons:

Blue Shield Select PPO discontinued in San Diego County for 2026
Blue Shield 65 Plus HMO only provides specialty access to UCSD with referrals and authorization

United Healthcare

Massive disruption: AARP United Healthcare Medicare Advantage PPO discontinued in San Diego County beginning January 1, 2026

The "Guaranteed Issue" Opportunity

Critical information for affected patients: If your Medicare Advantage plan is being terminated (UnitedHealthcare PPO, Humana Choice PPO, Blue Shield Select PPO, or UCSD Health Humana HMO), you are entitled to a Special Enrollment Period (SEP) and guaranteed acceptance to a Medicare Supplement plan.

This is huge: Even if you have been diagnosed with prostate cancer and are currently undergoing treatment, you can enroll in Medicare Supplement Plan G without medical underwriting if your plan is being discontinued.

Action required: You must act during the Annual Enrollment Period (October 15 - December 7) or during your Special Enrollment Period triggered by plan termination.

Real Member Experiences

From support group members and local reports:

Access barriers: Multiple members report:

Delays in prior authorization for PSMA PET scans (2-3 weeks typical)
Denials for Pluvicto requiring appeals
Inability to access UCSD specialists without changing entire insurance plan
Forced to choose between keeping oncologist or keeping insurance plan

Financial impact: Patients staying at Scripps were forced to switch to Medicare Supplement plans costing "upwards of 350 dollars more per month"

Treatment disruption: One patient spent two years dealing with insurance issues when denied coverage for gastric cancer treatment at UC San Diego under his Advantage plan through SCAN

Special Needs Plans (C-SNPs)

San Diego County offers 33 Special Needs Plan options for 2026, with 21 costing nothing beyond the Part B premium and 50% achieving 4 stars or better

However: C-SNPs (Chronic Special Needs Plans) do not include cancer as a qualifying chronic condition. Heart disease, diabetes, and other chronic conditions qualify, but prostate cancer does not.

D-SNPs (Dual Special Needs Plans) are available if you qualify for both Medicare and Medi-Cal: The leading D-SNP is CommuniCare Advantage with 8,828 members, followed by Blue Shield TotalDual Plan with 7,114 enrollees

Network Adequacy Concerns

San Diego County Medicare Advantage market now faces serious network adequacy questions:

Major academic medical centers:

❌ UCSD: Severely restricted or no access on most MA plans
❌ Scripps: No access on any MA plans
✓ Sharp: Available only on Sharp-affiliated plans
✓ Kaiser: Available only on Kaiser plans (closed system)

For complex cancer care requiring multiple specialists and advanced treatments, this creates a critical access problem.

What Our Support Group Members Should Do

If you're currently on Medicare Advantage:

Check your 2026 Annual Notice of Change (ANOC) - Did your plan drop UCSD or Scripps?
Verify your oncologist's network status - Call both your insurance and your doctor's office
If your plan is being discontinued: You have guaranteed issue rights to Medicare Supplement - use them!
If you're in active treatment: Contact UCSD or your provider to inquire about "continuity of care" exceptions (though Scripps stated no exceptions would be made, even for cancer patients in active treatment)

If you're approaching age 65:

Strongly consider Medicare Supplement Plan G during your guaranteed issue window
Do not assume "I'll switch later if I need it" - once you have a cancer diagnosis, you likely cannot switch
Calculate true costs:
- MA plan: $0/month premium + risk of $8,000+ out-of-pocket + access restrictions + potential treatment delays
- Medigap G: $230-400/month premium + $288/year deductible + unrestricted nationwide access + no treatment delays
Remember: With advanced prostate cancer, you may need treatments at multiple facilities (PSMA PET at UCSD, Pluvicto infusion, radiation at specialized center, second opinion at City of Hope or Johns Hopkins)

The Uncomfortable Truth

Scripps CEO Chris Van Gorder said there was one big thing to understand: "It's important for people to understand that Medicare Advantage is not Medicare". He characterized the industry as operating on "a game of delay, deny and not pay".

Insurance expert Pat Salas called the changes "the largest disruption to access in San Diego history".

For prostate cancer patients in San Diego County, the Medicare Advantage market has become increasingly hostile to accessing high-quality specialty care. The combination of Scripps' complete exit and UCSD's severe restrictions means that Medicare Advantage plans no longer provide reliable access to the region's top cancer care facilities.

Resources for San Diego Patients

Free Medicare counseling:

HICAP (Health Insurance Counseling and Advocacy Program): 858-565-8772
UC San Diego Health insurance questions: 800-926-8273, Option 7

To verify UCSD acceptance:

Official page: health.ucsd.edu/insurance-billing/accepted-health-plans/medicare/

Medicare plan comparison:

Medicare.gov plan finder
Licensed insurance brokers (no cost to you)

The bottom line: If you have prostate cancer or are at risk, and you value access to UCSD Moores Cancer Center (San Diego's only NCI-designated Comprehensive Cancer Center), Medicare Supplement Plan G is increasingly becoming the only reliable option in San Diego County. The "savings" from $0-premium Medicare Advantage plans may come at the cost of access to the advanced treatments that could save your life.

SIDEBAR: Part D Prescription Drug Coverage for Prostate Cancer Patients - Critical Updates for 2026

The Good News: Major Improvements from the Inflation Reduction Act

For prostate cancer patients facing expensive medication regimens, the Inflation Reduction Act has brought the most significant improvements to Medicare Part D in the program's history. These changes are making a real difference for our members.

The $2,100 Cap: A Game-Changer

The headline benefit: The out-of-pocket cap for prescription drugs is increasing to $2,100 in 2026 (up from $2,000 in 2025). Once you hit this cap, all your medications are covered at zero cost for the remainder of the year.

Why this matters: Many advanced prostate cancer treatments cost thousands of dollars per month. Before this change, patients could face $5,000-$10,000+ in annual out-of-pocket costs due to the notorious "donut hole" coverage gap. That gap is now gone.

Real-world example: If you're on Xtandi (enzalutamide), which can cost $12,000+ per month retail:

Old system (pre-2025): You could pay $6,000+ out-of-pocket annually
New system (2026): Maximum $2,100 out-of-pocket, then zero for the rest of the year

The 25% Rule: Why Most Patients Never Hit the Cap

Here's something most people don't understand about the $2,100 cap - and it's actually good news:

Medicare requires you to pay 25% coinsurance on brand-name medications, but here's the key: even if you only pay a $50 copay on a $1,000 medication, the system applies the full 25% ($250) toward your $2,100 maximum.

What this means: Most prostate cancer patients on typical ADT medications will never actually reach the $2,100 cap because the credited amounts exceed what they pay out-of-pocket.

Example:

Your oncologist prescribes a medication with a retail cost of $8,000/month
Your Part D plan copay: $200/month
Amount credited to your cap: $2,000/month (25% of $8,000)
Result: You hit the $2,100 cap after just over one month, then pay $0 for remaining medications all year

Important Exceptions: Generics Don't Count

Critical detail: Tier 1 and Tier 2 generic medications do NOT count toward your $2,100 maximum out-of-pocket. Only brand-name and higher-tier medications count.

This affects: Patients on generic bicalutamide (Casodex), finasteride (Proscar), or other generic medications - your generic costs won't help you reach the cap.

Common Prostate Cancer Medications: 2026 Cost Considerations

ADT (Androgen Deprivation Therapy) Medications

Lupron Depot (leuprolide acetate):

Typically Tier 3 or 4
Often covered but may require prior authorization
Injectable administered in doctor's office (usually covered under Part B, not Part D)

Firmagon (degarelix):

Tier 4 or 5 on most formularies
May require step therapy (trying Lupron first)
Watch for formulary placement changes mid-year

Orgovyx (relugolix):

Newest oral GnRH antagonist
Often Tier 4 or 5 (expensive tier)
Some plans require prior authorization showing medical necessity for oral vs. injectable

AR Pathway Inhibitors (Advanced Disease)

Xtandi (enzalutamide):

Tier 5 (specialty tier) on most plans
Retail cost: $12,000-15,000/month
Before hitting cap: Typically $300-500/month copay
After hitting $2,100 cap: $0/month
Prior authorization almost always required

Erleada (apalutamide):

Tier 5 (specialty tier)
Similar cost structure to Xtandi
May require documented progression or specific clinical criteria

Nubeqa (darolutamide):

Tier 5 (specialty tier)
Newer agent - some plans require trying Xtandi or Erleada first
Watch out for "step therapy" requirements

Zytiga (abiraterone acetate):

MAJOR CHANGE: Generic abiraterone now widely available
Generic: Often Tier 3 (much lower cost)
Brand Zytiga: Tier 4-5 (if brand medically necessary)
Most plans will require generic unless documented intolerance

Chemotherapy Agents

Jevtana (cabazitaxel):

Typically administered IV in clinic
Usually covered under Part B (medical), not Part D
But some oral preparations may fall under Part D

Taxotere (docetaxel):

Generic available
Usually Part B coverage (IV administration)

Oral Medications and Special Cases

Provenge (sipuleucel-T):

Immunotherapy
Covered under Part B, not Part D (administered via IV)
Not subject to Part D formularies or caps

Xofigo (radium Ra 223 dichloride):

Covered under Part B, not Part D (IV administration)
For bone metastases

Pluvicto (lutetium Lu 177 vipivotide tetraxetan):

Covered under Part B, not Part D (IV administration)
Subject to Medicare Advantage prior authorization issues (see main article)
Original Medicare + Medigap: straightforward coverage

The $615 Deductible - And How to Avoid It

If your plan has a deductible, the maximum allowed will rise to $615 for 2026.

Key point: Many Part D plans have zero deductible or lower deductibles. When choosing your plan, look for:

"$0 deductible" plans
Plans that exempt certain tiers from deductible
Plans that cover generics before deductible

Strategic tip: If you're on expensive medications, paying a slightly higher monthly premium ($10-30/month more) for a plan with no deductible can save you $615 in January.

The Insulin Cap (Relevant for Diabetic Patients)

The $35/month cap on insulin remains in place for 2026, and plans cannot apply a deductible to covered insulin products.

Why this matters for prostate cancer patients: ADT therapy increases risk of diabetes and metabolic syndrome. If you develop diabetes during treatment, your insulin is capped at $35/month regardless of type or quantity.

The Medicare Prescription Payment Plan: Spreading Costs

New for 2025-2026: Members enrolled in the Medicare Prescription Payment Plan will be automatically re-enrolled for 2026, provided they remain on the same plan.

How it works: Instead of paying large amounts upfront for expensive medications, Medicare spreads your out-of-pocket costs evenly over the year.

Example without payment plan:

January: Xtandi prescription, you pay $500
February: Xtandi refill, you pay $400
March: Xtandi refill, you pay $300
April: Xtandi refill, you pay $200
May: Xtandi refill, you pay $200
June: Hit $2,100 cap, pay $0 rest of year

Example WITH payment plan:

January through December: You pay approximately $175/month ($2,100 ÷ 12)
Predictable monthly cost
Still hit the same $2,100 cap

How to enroll: Contact your Part D plan directly. This is handled by your insurance carrier, not your pharmacy.

Low-Income Subsidy (Extra Help): Critical for Fixed Incomes

Members who qualify for the Low-Income-Subsidy (LIS) will pay up to $5.10 for generic or preferred drugs and up to $12.65 for brand-name drugs during the initial coverage phase.

2026 Qualification thresholds:

Individual: Income under approximately $23,000, resources under $16,000
Married couple: Income under approximately $31,000, resources under $32,000

What "resources" means:

Bank accounts
Stocks and bonds
Does NOT include: Your home, one car, personal belongings, life insurance

How to apply:

Online: ssa.gov
Phone: 1-800-772-1213
Through your Medicare agent (takes about 4 minutes)

Why this matters: If you qualify for LIS, your most expensive prostate cancer medications cost only $12.65 per month - a massive savings from the hundreds you'd otherwise pay.

Formulary Changes: The Hidden Threat

CRITICAL WARNING: Unlike Medicare Advantage plans which can only change during Annual Enrollment, Part D formularies can change at ANY time during the year.

What this means:

Your medication in Tier 3 (copay $47) in January could become Tier 5 (copay $400) in June
You cannot change plans mid-year even if your formulary changes unfavorably
You're stuck with higher costs until next Annual Enrollment Period

Real Support Group Member Experience:

"My Erleada was Tier 4 ($150/month copay) when I enrolled in October. In March, I went to refill and was told it's now Tier 5 ($450/month). I called my insurance - they said the formulary changed and there's nothing they can do. I can't switch plans until October. That's $1,800 more than I budgeted."

Protection strategy:

During Annual Enrollment, specifically verify tier placement for YOUR medications
Ask if the plan has made mid-year formulary changes in the past
Consider plans with reputation for formulary stability
Document your current tier placements in writing

Prior Authorization: The Part D Version

While less onerous than Medicare Advantage prior authorizations, Part D plans can still require:

Prior authorization for:

Tier 5 specialty medications (Xtandi, Erleada, Nubeqa)
Brand medications when generic available (brand Zytiga vs. generic abiraterone)
Medications exceeding "quantity limits"

Step therapy requirements:

"Try generic abiraterone before brand Zytiga"
"Try Lupron injection before Orgovyx oral"
"Document failure of first-line therapy before Xtandi"

Your oncologist's office handles this, but it can delay treatment start by 1-2 weeks. Plan ahead when starting new medications.

Quantity Limits: Watch for Dose Restrictions

Some Part D plans impose quantity limits:

Examples:

Xtandi: 120 capsules per 30 days (standard dose is 4 capsules daily)
Erleada: 120 tablets per 30 days (standard dose is 4 tablets daily)

What happens if you need more:

Prior authorization required showing medical necessity
May need oncologist to document dose escalation
Some plans refuse to cover above-standard doses

The "Preferred Pharmacy" Strategy

Most Part D plans have preferred pharmacy networks where your copays are lower:

Example copay structure:

Tier 3 at preferred pharmacy: $47
Tier 3 at non-preferred pharmacy: $100
Savings: $53 per fill

Common preferred pharmacies in San Diego:

CVS (many plans)
Walgreens (many plans)
Costco (some plans)
Independent pharmacies (varies by plan)

Mail order: Often treated as "preferred" with 90-day supply option and reduced copays.

Specialty Pharmacies: Required for Expensive Meds

Tier 5 medications (Xtandi, Erleada, Nubeqa) often must be filled at specialty pharmacies:

Common specialty pharmacy networks:

CVS Specialty
Walgreens Specialty
Accredo (Express Scripts)
OptumRx Specialty

What this means:

You cannot use your regular local pharmacy
Medications typically shipped to your home
Require coordination between oncologist and specialty pharmacy
May have different copay structures

Medicare Part D vs. Part B: What's Covered Where?

This is crucial for prostate cancer patients:

Part D (Prescription Drug Plans) covers:

Oral medications you pick up at pharmacy
- Xtandi, Erleada, Nubeqa, Zytiga/abiraterone
- Orgovyx (oral GnRH antagonist)
- Pain medications, anti-nausea medications

Part B (Medical Insurance) covers:

Medications administered by IV or injection in doctor's office or infusion center
- Lupron, Firmagon (injectable ADT)
- Provenge (immunotherapy)
- Xofigo (radium-223)
- Pluvicto (Lu-177-PSMA)
- Chemotherapy (docetaxel, cabazitaxel)

Why this distinction matters:

Part B coverage is subject to Medicare Advantage prior authorization barriers
Part D coverage has the $2,100 out-of-pocket cap
Different appeals processes
Different formularies and restrictions

How to Choose the Right Part D Plan for 2026

Step-by-Step Process:

1. Make a complete medication list:

Include ALL current medications (not just cancer-related)
Note dosages and frequencies
Include medications you expect to start soon

2. Use Medicare.gov Plan Finder:

Enter your exact medications
Enter your preferred pharmacies
System calculates total annual cost for each plan
This is the most accurate way to compare

3. Pay attention to:

Total estimated annual cost (premiums + copays)
Formulary tier placement for YOUR medications
Deductible amount
Preferred pharmacy network
Mail order options
Star rating (4+ stars preferred)

4. Verify specialty pharmacy requirements:

Call plans to confirm Xtandi, Erleada, Nubeqa access
Ask about prior authorization requirements
Confirm specialty pharmacy partners

5. Check plan stability:

Has this plan made mid-year formulary changes?
What's the plan's star rating trend?
How long has the plan been available?

Common Mistakes to Avoid:

❌ Choosing the cheapest premium without checking drug costs

A $0 premium plan might cost you $3,000 in copays
A $50/month premium plan might cost you $1,200 in copays
Total annual cost matters, not monthly premium

❌ Not updating your plan annually

Formularies change every year
Your medications may change
What was the best plan in 2025 may be terrible in 2026

❌ Assuming generics don't matter

Even if you're on expensive brand medications, you likely take other drugs
Generic costs add up over the year
Optimizing for ALL medications matters

❌ Ignoring the preferred pharmacy network

Using non-preferred pharmacy can double your copays
$50/month extra = $600/year wasted

❌ Not considering mail order

90-day supply often cheaper than three 30-day fills
Convenient for maintenance medications
Often required for specialty medications anyway

Special Considerations for Clinical Trial Participants

If you're in a clinical trial:

Investigational drugs: Not covered by Part D (or Part B). These are provided by the trial sponsor at no cost.

"Routine care" costs: Medicare Part D covers your other medications during the trial, but some plans have exclusions for "experimental" related care.

Coordination: Your trial coordinator should help navigate insurance coverage for supportive care medications.

The Premium Structure: What You'll Pay

Most San Diego Part D plans fall into these categories:

$0-10/month plans:

Often higher copays
May have deductibles
Good for patients on mostly generics

$15-40/month plans:

Moderate copays
May have zero deductible
Good middle-ground option

$60-120/month plans:

Lower copays on brand medications
Often zero deductible
May be cheaper overall if you're on Xtandi, Erleada, or Nubeqa

Calculation example:

Plan A: $0 premium, $400/month Xtandi copay = $0 + $2,100 cap = $2,100/year
Plan B: $80 premium, $200/month Xtandi copay = $960 + $2,100 cap = $3,060/year
Plan A saves you $960 annually

The math changes if you take multiple brand medications, where the higher-premium plan might optimize costs across your entire regimen.

IRMAA Impact on Part D

Remember: If your income exceeds IRMAA thresholds, you pay additional Part D premiums:

2025 IRMAA surcharges (2026 amounts pending):

Income $103,000-129,000 (individual): +$12.90/month
Income $129,000-161,000 (individual): +$33.30/month
Income $161,000-193,000 (individual): +$53.80/month
Income over $500,000 (individual): +$81.00/month

This is in ADDITION to your plan premium.

The Appeals Process for Part D Denials

If your medication is denied or not covered:

Level 1: Plan reconsideration (24-72 hours for standard, 24 hours for expedited)

Your doctor submits prior authorization with medical justification
Plan reviews and approves or denies

Level 2: Independent review (7 days standard, 72 hours expedited)

If denied at Level 1, automatically forwarded to independent reviewer
Outside entity reviews medical necessity

Level 3: Administrative Law Judge

For denials involving $200+ value
More formal hearing process

Expedited appeals: Available when delay could "seriously jeopardize your life or health" - standard for cancer medications.

Your oncologist's office typically handles this process, but stay involved and follow up.

Key Medications to Research for 2026

If you're currently taking or may need:

Tier 4-5 (expensive) medications:

Xtandi (enzalutamide)
Erleada (apalutamide)
Nubeqa (darolutamide)
Brand Zytiga (if generic intolerable)
Orgovyx (relugolix)

Tier 2-3 (moderate cost) medications:

Generic abiraterone acetate
Generic bicalutamide
Finasteride
Dutasteride

Watch for tier changes and prior authorization requirements on ALL of these.

Resources for Part D Navigation

Medicare Plan Finder:

medicare.gov/plan-compare
Enter your exact medications
Compare total annual costs

State Health Insurance Assistance Program (SHIP):

California: HICAP (Health Insurance Counseling and Advocacy Program)
San Diego: 858-565-8772
Free, unbiased counseling

Pharmaceutical Assistance Programs:

Many manufacturers offer copay assistance
Not all programs work with Medicare (legal restrictions)
Ask your oncologist's office about available programs

Licensed Medicare agents:

Free service (compensated by insurers)
Can help navigate complex medication needs
Should review your specific drugs in plan finder

Bottom Line for Prostate Cancer Patients

The $2,100 cap is a massive improvement that makes expensive prostate cancer medications affordable for the first time. However:

✓ Do review your plan every year - formularies change ✓ Do use Medicare.gov plan finder with your actual medications ✓ Do consider total annual cost, not just monthly premium
✓ Do verify tier placement for Xtandi, Erleada, Nubeqa specifically ✓ Do enroll in Extra Help if you qualify ✓ Do use preferred pharmacies to minimize copays

✗ Don't assume your current plan is still optimal ✗ Don't forget to account for Part B medications (Lupron, Pluvicto, etc.) ✗ Don't ignore mid-year formulary change risk ✗ Don't choose based on premium alone

For our members on advanced therapies: The combination of the $2,100 cap and proper Part D plan selection can save you $5,000-8,000 annually compared to pre-Inflation Reduction Act costs. Take the time during Annual Enrollment (October 15 - December 7) to optimize your coverage.

Questions about Part D? Bring your medication list to our monthly meetings, and we can help you navigate the plan selection process.

Sources:

Centers for Medicare & Medicaid Services. (2025). "2026 Medicare Part D Changes." CMS.gov. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin
HealthyMarks Insurance. (2025). "What's New for San Diego Medicare in 2026." https://healthymarks.com/whats-new-for-san-diego-medicare-in-2026/
Social Security Administration. (2025). "Extra Help with Medicare Prescription Drug Plan Costs." SSA.gov. https://www.ssa.gov/benefits/medicare/prescriptionhelp/
Medicare.gov. (2026). "Medicare Plan Finder." https://www.medicare.gov/plan-compare/

Part D Prescription Drug Plans for Advanced mCRPC Patients in San Diego: A Detailed Cost Analysis for 2026

The Challenge for Advanced Prostate Cancer Patients

For men with metastatic castration-resistant prostate cancer (mCRPC) requiring expensive medications like Xtandi (enzalutamide), Erleada (apalutamide), or Nubeqa (darolutamide), choosing the right Medicare Part D Prescription Drug Plan (PDP) is absolutely critical. These medications can cost $12,000-15,000 per month at retail prices, making proper insurance coverage the difference between affordable treatment and financial devastation.

The good news: The Inflation Reduction Act's $2,100 out-of-pocket cap for 2026 has fundamentally changed the math. The complexity: Not all Part D plans handle expensive specialty medications the same way, and choosing the wrong plan can still cost you thousands more than necessary.

Understanding Xtandi Coverage and Costs

Xtandi: The Baseline Scenario

99% of Medicare Part D patients are covered for Xtandi, but coverage doesn't mean affordability without understanding the details.

Retail pricing reality:

Monthly cost: Approximately $12,000-15,000
Annual cost without insurance: $144,000-180,000
Per-pill cost: $73-100+

Typical Part D tier placement:

Tier 5 (Specialty Tier) on most plans
Requires specialty pharmacy (CVS Specialty, Walgreens Specialty, Accredo, OptumRx)
Prior authorization almost always required
Not available at retail pharmacies

The 2026 Out-of-Pocket Cap: How It Works

The out-of-pocket cap for prescription drugs is $2,100 in 2026 (up from $2,000 in 2025).

What this means for an mCRPC patient on Xtandi:

Scenario: Patient paying 33% coinsurance on Tier 5 medication

Month	Retail Cost	Your 33% Coinsurance	Cumulative OOP	Status
January	$12,000	$615 (deductible) + $500	$1,115	Paying
February	$12,000	$500	$1,615	Paying
March	$12,000	$485	$2,100	Cap reached
April-December	$12,000/mo	$0	$2,100	Covered 100%

Total annual out-of-pocket: $2,100 (vs. $144,000+ without insurance)

Key insight: Because Xtandi is so expensive, you'll likely hit the $2,100 cap within 2-3 months, then pay nothing for the rest of the year for ALL your Part D medications.

2026 Standalone Part D Plan Landscape in San Diego

Market Overview: Shrinking Options

The total number of standalone prescription drug plans will drop to 360 nationwide in 2026, down from 464 in 2025. Major carriers like Cigna Healthcare will no longer offer Medicare Part D prescription plans in 2026, with former plans now available from HealthSpring, and Anthem does not offer standalone Part D plans in California.

Average premium trends: For standalone Part D prescription drug plans, the average total premium is expected to fall from $38.31 to $34.50 in 2026, but this average masks significant variation.

Major Standalone PDP Carriers Available in San Diego (2026)

1. Wellcare (Centene)

Wellcare Value Script
Wellcare Classic
Premium range: $0-45+ depending on specific plan and location
Coverage: Strong formulary, widely available
Note: Most popular PDP nationally

2. SilverScript (CVS/Aetna)

SilverScript Choice (consolidated to single plan)
SilverScript Choice faces the maximum $50 increase in 30 states but is decreasing in 20 others, with premiums ranging from $14.70 to $116
Note: Limited to one plan option now

3. AARP Medicare Rx (UnitedHealthcare)

AARP Medicare Rx Preferred
AARP Medicare Rx Saver
Coverage: Extensive network, multiple plan options
Premium: Varies by plan selection

4. Blue Shield Rx Plans

Blue Shield Rx Plus (PDP)
Blue Shield Rx Enhanced (PDP)
Note: Available in California, designed to pair with Medicare Supplement plans

5. Humana Prescription Drug Plans

Various tiers available
Premium: Range of options from low to moderate cost

Critical Factors for mCRPC Patients

Deductible: For plans that have an annual deductible, the 2026 limit set by Medicare is $615.

Not all plans have deductibles. For patients on Xtandi:

With $615 deductible: You pay $615 in January before coinsurance starts
With $0 deductible: Coinsurance starts immediately

Example impact:

Plan A: $0 premium, $615 deductible → First month you pay $615 + coinsurance
Plan B: $30/month premium, $0 deductible → First month you pay only coinsurance

For expensive specialty drugs, the deductible matters less because you'll hit the $2,100 cap quickly either way.

Calculating True Cost: The Formula That Matters

For mCRPC patients on Xtandi or similar expensive medications, here's the calculation:

Total Annual Cost = (Monthly Premium × 12) + Out-of-Pocket Drug Costs (capped at $2,100)

Example comparison:

Plan	Monthly Premium	Annual Premium	Drug OOP	Total Annual Cost
Plan A	$0	$0	$2,100	$2,100
Plan B	$30	$360	$2,100	$2,460
Plan C	$80	$960	$2,100	$3,060

Important caveat: This assumes the medication is on the formulary at a reasonable tier. If a plan places Xtandi on Tier 5 with 50% coinsurance vs. 33% coinsurance, you'll hit the $2,100 cap at different rates.

Specialty Pharmacy Requirements

Xtandi is available only through a specialty mail-order pharmacy.

What this means:

You cannot pick up Xtandi at your local CVS or Walgreens retail location
Medication ships to your home
Coordination required between oncologist, plan, and specialty pharmacy

Major specialty pharmacy networks:

CVS Specialty Pharmacy
Walgreens Specialty Pharmacy
Accredo (Express Scripts network)
OptumRx Specialty
BriovaRx

Check before enrolling: Verify which specialty pharmacies your chosen Part D plan contracts with. If your oncologist has an established relationship with a specific specialty pharmacy, choosing a plan that works with that pharmacy can simplify coordination.

Prior Authorization: What to Expect

For Xtandi in particular, additional methods of treatment may need to be attempted first before Xtandi can be prescribed as a covered medication. This is because Xtandi is meant to be used as a treatment option when other treatment methods have proven unsuccessful.

Typical prior authorization requirements for AR pathway inhibitors:

For Xtandi, Erleada, Nubeqa:

Documentation of castration-resistant disease
PSA progression despite ADT
Imaging showing metastatic disease (for mCRPC indication)
Performance status documentation
Oncologist's treatment plan

Timeline:

Standard prior authorization: 72 hours
Expedited (urgent): 24 hours
Your oncologist's office handles this process

Step therapy concerns: Some plans require "step therapy" (try drug A before drug B), but for mCRPC patients, clinical guidelines support these medications as appropriate first-line therapy in the castration-resistant setting.

The Medicare Prescription Payment Plan Option

Medicare members with Part D coverage can spread their prescription drug out-of-pocket costs into monthly payments over the course of the plan year. Enrollment is voluntary, and you will need to opt in through your plan provider.

How it works for Xtandi patients:

Without payment plan:

January: Pay $615 (deductible) + $500 (coinsurance) = $1,115
February: Pay $500 = $500
March: Pay $485 to reach $2,100 cap
April-December: Pay $0

With payment plan:

January-December: Pay approximately $175/month ($2,100 ÷ 12 months)

Who benefits:

Patients who cannot afford $1,000+ upfront in first 2-3 months
Those on fixed incomes needing predictable monthly costs
Anyone who prefers to spread costs evenly

To enroll: Contact your Part D plan directly after enrollment

Extra Help (Low Income Subsidy): Massive Savings

Members who qualify for the Low-Income-Subsidy (LIS) will pay up to $5.10 for generic or preferred drugs and up to $12.65 for brand-name drugs.

Qualification for 2026:

Individual income under ~$23,000, resources under $16,000
Married couple income under ~$31,000, resources under $32,000

Impact on Xtandi costs:

Without Extra Help: Up to $2,100/year out-of-pocket
With Extra Help: $12.65/month maximum = $151.80/year

That's $1,948 in annual savings. If you're anywhere close to these income/asset limits, apply immediately.

How to apply:

Online: ssa.gov
Phone: 1-800-772-1213
Through licensed Medicare agent (4-minute process)

Future Pricing: Xtandi Price Negotiations

Important development: Enzalutamide (Xtandi) has been included in the second round of Medicare drug price negotiations under the Inflation Reduction Act, with negotiations taking place in 2025 and negotiated prices effective in 2027.

What this means:

2026: Current pricing remains (covered under $2,100 cap)
2027: Negotiated lower prices take effect
The first negotiation cycle achieved 38% to 79% price reductions, saving $1.5 billion in out-of-pocket costs for Medicare beneficiaries in 2026

Practical impact: If Xtandi sees similar price reductions (38-79%), your coinsurance amounts will decrease, meaning you'll either:

Hit the $2,100 cap more slowly (spreading payments over more months)
Pay less total if you don't hit the cap (unlikely with Xtandi's high cost)

Comparing to Medicare Advantage Plans with Drug Coverage

Many San Diego residents are on Medicare Advantage plans that include drug coverage (MA-PD plans). For mCRPC patients, this comparison is critical:

Medicare Advantage + Drug Coverage (MA-PD)

Pros:

Often $0 premium for the plan
Includes medical AND drug coverage
Same $2,100 drug cap applies

Cons:

Network restrictions (UCSD access severely limited - see main article)
Prior authorization barriers for expensive drugs
Formulary restrictions may be tighter
Can be difficult to get Pluvicto or advanced treatments (Part B coverage issues)

Original Medicare + Medigap + Standalone PDP

Pros:

Unrestricted access to UCSD Moores Cancer Center
No network restrictions for oncologists
Part B medications (Pluvicto, Xofigo) covered without MA prior auth
Freedom to see any Medicare provider nationwide

Cons:

Medigap premium: $230-400/month ($2,760-4,800/year)
PDP premium: $0-80/month ($0-960/year)
Higher upfront costs

Total cost comparison for mCRPC patient on Xtandi:

Option A: Medicare Advantage

Plan premium: $0/year
Xtandi costs: $2,100/year (cap)
Total: $2,100/year
BUT: Potential Pluvicto denials, limited UCSD access, network restrictions

Option B: Medigap + PDP

Medigap premium: $3,600/year (example: $300/month)
PDP premium: $360/year (example: $30/month)
Xtandi costs: $2,100/year (cap)
Total: $6,060/year
BUT: Unrestricted UCSD access, no Pluvicto denials, nationwide provider access

The $4,000 question: Is unrestricted access to UCSD Moores Cancer Center and seamless Part B medication coverage worth $4,000/year more?

For advanced mCRPC patients: Many support group members say yes—especially those needing:

PSMA PET imaging (better at UCSD)
Pluvicto treatment (Part B, subject to MA denials)
Clinical trials (often at academic centers)
Second opinions at top cancer centers

Formulary Changes: The Hidden Threat

Critical warning: We can make changes to the pharmacies that are part of our plan during the year, and formularies can change mid-year.

What happened to real members: "My Erleada was Tier 4 ($150/month) when I enrolled. In March, it became Tier 5 ($450/month). I couldn't switch plans until October."

Protection strategies:

Document current tier placement when you enroll
Ask specifically: "Has this plan made mid-year formulary changes in past years?"
Check plan stability: 4-5 star rated plans less likely to make disruptive changes
Get it in writing: Save the formulary showing Xtandi's tier placement

Step-by-Step: Choosing Your Plan

For San Diego mCRPC Patients on Xtandi:

Step 1: List ALL your medications

Xtandi or other AR pathway inhibitor
Lupron/Firmagon (if applicable - this is Part B, not Part D)
Pain medications
Bone-strengthening agents
Any other prescriptions

Step 2: Use Medicare.gov Plan Finder

Go to medicare.gov/plan-compare
Enter ZIP code: 92XXX (San Diego area)
Enter ALL medications with exact dosages
Select preferred pharmacies (including specialty)

Step 3: Review Results The calculator shows:

Total estimated annual cost (premium + drug costs)
Which tier each drug is placed on
Deductible amount
Whether prior authorization is required

Step 4: Verify Specialty Pharmacy

Call top 2-3 plans
Ask: "Which specialty pharmacies do you contract with for Xtandi?"
Confirm: "Is Xtandi Tier 5, and what's the coinsurance percentage?"

Step 5: Check Plan Stability

Star rating (prefer 4+ stars)
How long has plan been available?
Check reviews on medicare.gov

Real Example from Medicare.gov Plan Finder

Hypothetical San Diego patient taking:

Xtandi 160mg daily
Metformin 1000mg twice daily (generic diabetes medication)

Plan A: SilverScript Choice

Monthly premium: $45
Annual premium: $540
Deductible: $590
Xtandi: Tier 5, 33% coinsurance
Estimated annual drug cost: $2,100 (hits cap)
Total annual cost: $2,640

Plan B: Wellcare Value Script

Monthly premium: $0
Annual premium: $0
Deductible: $615
Xtandi: Tier 5, 33% coinsurance
Estimated annual drug cost: $2,100 (hits cap)
Total annual cost: $2,100

Winner for this patient: Plan B saves $540/year

Note: Actual results vary based on exact medications, location, and plan availability

Important Reminders

Manufacturer copay assistance: The XTANDI Patient Savings Program is for eligible patients with commercial prescription insurance coverage and is not valid for patients whose prescription claims are reimbursed by any state or federal government program, including Medicare.

Translation: If you're on Medicare, you cannot use Astellas' patient assistance program for Xtandi. The $2,100 cap is your protection instead.

IRMAA considerations: If your income triggers IRMAA surcharges, you'll pay additional Part D premiums on top of your plan premium. Factor this into your calculations.

Annual review is mandatory: Even if you're happy with your 2025 plan, you must review for 2026. Formularies change, tiers change, premiums change.

Support Group Recommendations for mCRPC Patients

Priority 1: Hit the $2,100 cap as fast as possible With Xtandi's high cost, you'll hit it in 2-3 months anyway. Choose plans that:

Minimize total annual cost (premium + $2,100)
Have established specialty pharmacy relationships
Show formulary stability (4+ star ratings)

Priority 2: Consider Medigap + PDP if you need UCSD The extra $4,000/year may be worth it for:

Unrestricted UCSD Moores Cancer Center access
No prior authorization delays on Pluvicto
Freedom to seek second opinions anywhere
Clinical trial participation

Priority 3: Apply for Extra Help if eligible Even if you think you might not qualify, apply. The $1,950/year savings is substantial.

Priority 4: Enroll in Payment Plan if cash flow is tight Spreading the $2,100 over 12 months ($175/month) is easier for many on fixed incomes than paying $1,000+ in month 1-2.

Resources

Medicare Plan Finder:

medicare.gov/plan-compare
Enter your actual medications
Compare total annual costs

HICAP (Free counseling):

San Diego: 858-565-8772
Health Insurance Counseling and Advocacy Program
Free, unbiased assistance

Xtandi Support Solutions:

1-855-898-2634
Can help navigate coverage questions
Cannot help with copays (Medicare restrictions)

Licensed Medicare Agents:

Free service (insurers compensate them)
Can help with complex medication needs
Should use Plan Finder with your specific drugs

Bottom Line

For San Diego-area prostate cancer patients with mCRPC requiring Xtandi or similar expensive medications:

✓ The $2,100 cap makes these drugs affordable for the first time

✓ Choose lowest total cost (annual premium + $2,100 in most cases)

✓ Verify specialty pharmacy contracts before enrolling

✓ Consider Medigap + PDP if you need unrestricted UCSD access

✓ Review annually during October 15 - December 7

✓ Apply for Extra Help if income-eligible

✓ Use the Payment Plan if large upfront costs are difficult

The most expensive mistake is choosing based on premium alone without checking:

Xtandi's tier placement and coinsurance rate
Specialty pharmacy network
Prior authorization requirements
Plan's history of formulary stability

Take your complete medication list to our monthly meetings, and we can help you navigate the Plan Finder to optimize your 2026 coverage.

Sources:

Centers for Medicare & Medicaid Services. (2025). "Part D Coverage in 2026." Medicare.gov. https://www.medicare.gov/health-drug-plans/part-d/basics/costs
Astellas Pharma. (2025). "XTANDI Pricing Information." XtandiPricing.com. https://www.xtandipricing.com/
Astellas Pharma. (2025). "XTANDI Support Solutions." Xtandi.com. https://www.xtandi.com/financial-support
HealthyMarks Insurance. (2025). "What's New for San Diego Medicare in 2026." https://healthymarks.com/whats-new-for-san-diego-medicare-in-2026/
UnitedHealthcare. (2025). "How Medicare Part D will change in 2026." UHC.com. https://www.uhc.com/medicare/medicare-education/part-d-changes.html
KFF. (2025). "Medicare Part D in 2026: 4 notes." Becker's Payer Issues. https://www.beckerspayer.com/payer/medicare-part-d-in-2026-4-notes/
CMS. (2025). "Enzalutamide included in next round of Medicare drug price negotiations." Urology Times. https://www.urologytimes.com/view/enzalutamide-included-in-next-round-of-medicare-drug-price-negotiations

Sidebar: Trap for Senior Homeowners. Capital Gains from Principal Residence Sales Affect Medicare IRMAA

Understanding the IRMAA Impact

IRMAA (Income-Related Monthly Adjustment Amount) is calculated based on your Modified Adjusted Gross Income (MAGI) from two years prior. This creates a scenario where a one-time spike in income from selling your home can trigger significantly higher Medicare premiums for an entire year, even though it's not reflective of your actual ongoing income.

The Principal Residence Exclusion

Under IRS rules (Section 121), you can exclude:

$250,000 in capital gains (single filers)
$500,000 in capital gains (married filing jointly)

Requirements:

Owned and lived in the home as your principal residence for at least 2 of the last 5 years
Haven't used this exclusion in the past 2 years

What Counts Toward IRMAA

Here's the critical issue: Any capital gains ABOVE the exclusion amount are added to your MAGI, which is used to calculate your IRMAA.

Example Scenario:

Let's say you're married and sell your San Diego home in 2025:

Purchase price (20 years ago): $300,000
Sale price: $1,200,000
Capital gain: $900,000
Exclusion (married): -$500,000
Taxable gain: $400,000

This $400,000 gets added to your 2025 MAGI, which will determine your 2027 Medicare premiums (remember the 2-year lookback).

2025 IRMAA Thresholds and Surcharges

Based on your MAGI from 2023 (for 2025 premiums):

Filing Status	MAGI	Part B Monthly Premium	Part D Monthly Premium Added
Individual	≤$103,000	$185.00	$0
Individual	$103,001-$129,000	$259.00	$12.90
Individual	$129,001-$161,000	$370.00	$33.30
Individual	$161,001-$193,000	$480.00	$53.80
Individual	$193,001-$500,000	$590.00	$74.20
Individual	>$500,000	$628.00	$81.00
Married Joint	≤$206,000	$185.00	$0
Married Joint	$206,001-$258,000	$259.00	$12.90
Married Joint	$258,001-$322,000	$370.00	$33.30
Married Joint	$322,001-$386,000	$480.00	$53.80
Married Joint	$386,001-$750,000	$590.00	$74.20
Married Joint	>$750,000	$628.00	$81.00

Real-World Impact Using Your Scenario

Let's say your normal retirement income is:

Social Security: $40,000
Pension: $60,000
Investment income: $30,000
Normal MAGI: $130,000 (married filing jointly)

Without home sale:

Part B premium: $185/month × 2 people = $370/month
Part D surcharge: $0
Annual cost: $4,440

With $400,000 capital gain added:

New MAGI: $530,000
Part B premium: $590/month × 2 people = $1,180/month
Part D surcharge: $74.20/month × 2 people = $148.40/month
Annual cost: $15,940.80
Additional cost for one year: $11,500.80

The Two-Year Lag Creates Planning Opportunities

Since IRMAA is based on income from two years prior, you have some planning flexibility:

Strategic Timing Options:

Sell before age 63: If you sell your home at 62, the income spike hits at age 62, but you don't enroll in Medicare until 65. The IRMAA lookback at age 65 goes to age 63 (after the sale impact).
Defer the sale: If you're 64 and planning to sell, consider whether waiting until after Medicare enrollment might make sense from a tax planning perspective.
Installment sale: Spreading the gain over multiple years through an installment sale could keep you in lower IRMAA brackets, though this has other tax implications.

Life-Changing Event Exceptions

Here's the good news: Social Security recognizes that one-time events shouldn't permanently affect your premiums. You can appeal your IRMAA determination if you experienced a "life-changing event."

Qualifying Life-Changing Events:

Marriage
Divorce or annulment
Death of spouse
Work stoppage or work reduction
Loss of income-producing property (due to disaster or other event beyond your control)
Loss or reduction of certain kinds of pension income
Receipt of a settlement from an employer or former employer

The Problem with Home Sales

Unfortunately, a voluntary sale of a principal residence is NOT listed as a qualifying life-changing event for IRMAA appeals. This is a significant gap in the policy that affects many retirees.

However, there are scenarios where you might qualify:

Involuntary conversion (home destroyed by fire, flood, earthquake - then you sell the land)
Forced sale due to employment relocation
Sale after death of spouse (the death is the qualifying event)

Form SSA-44: The IRMAA Appeal

If you believe you qualify for an IRMAA reduction due to a life-changing event, you file Form SSA-44 (Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event).

You must provide:

Documentation of the life-changing event
Evidence of your current income (not the income from 2 years ago)
Tax returns

The appeal must show that your current income is significantly lower than the income from the lookback year.

Practical Strategies to Minimize IRMAA Impact

1. Maximize the Exclusion

Ensure you fully qualify for the $250,000/$500,000 exclusion:

Document your 2-of-5-years residency
If divorced, understand how the exclusion is split
Consider timing if you're close to the 2-year residency requirement

2. Consider a 1031 Exchange

If you're selling a principal residence but plan to buy another:

A 1031 exchange allows you to defer capital gains by rolling proceeds into a new property
Important limitation: 1031 exchanges typically apply to investment property, not principal residences
However, you could potentially convert your home to a rental before selling, though this is complex and requires careful tax planning

3. Opportunity Zone Investment

If you have significant capital gains:

Invest gains in a Qualified Opportunity Zone Fund within 180 days
Defer capital gains until 2026 or when you sell the Opportunity Zone investment
This defers the MAGI spike to a different tax year
Check if this strategy affects your specific situation with a tax advisor

4. Charitable Remainder Trust (CRT)

For high-value properties:

Transfer the property to a CRT before sale
The trust sells the property (tax-free to the trust)
You receive income stream for life
Remainder goes to charity
This spreads income over many years and provides a charitable deduction
Complex strategy requiring specialized legal and tax advice

5. Installment Sale

If selling to a family member or in certain situations:

Structure as an installment sale
Recognize gain over multiple years
Keeps each year's income lower
Must follow strict IRS rules to avoid having entire gain recognized immediately

6. Roth Conversion Strategy

If you're anticipating IRMAA impact anyway:

Consider doing Roth IRA conversions in the same year as the home sale
You're already in a high IRMAA bracket for that year
Future Roth distributions won't count toward MAGI
This is advanced planning but can provide long-term benefits

7. Timing Around Medicare Enrollment

If you're working past 65 with employer coverage, you might delay Medicare enrollment
Sell the home while still on employer coverage
By the time you enroll in Medicare, the home sale income is beyond the 2-year lookback
Must ensure continuous creditable coverage to avoid penalties

Special Consideration: California Proposition 19

If you're in California (relevant given your San Diego location), Proposition 19 (effective April 1, 2021) changed property tax rules:

Allows homeowners 55+ to transfer their property tax base to a new home anywhere in California (up to 3 times)
Can transfer to a more expensive home with an upward adjustment
This is separate from federal capital gains tax but affects the overall financial calculation

Documentation and Record Keeping

To maximize your exclusion and support any potential IRMAA appeal:

Keep records of:

Purchase price and date
All capital improvements (these increase your basis and reduce capital gain)
Settlement statements
Proof of residency (utility bills, voter registration, etc.)
Moving expenses and timing
Any losses not covered by insurance
Documentation of any life-changing events

What To Do If You're Facing This Situation

Immediate Steps:

Calculate your expected capital gain
- Use your purchase price (basis)
- Add all capital improvements
- Subtract from expected sale price
- Apply the $250,000/$500,000 exclusion
Model the IRMAA impact
- Calculate your normal MAGI
- Add the taxable capital gain
- Determine which IRMAA bracket you'll fall into
- Calculate the additional premium cost
Consult with a tax professional
- Explore all available strategies
- Consider timing and structure of the sale
- Evaluate if any life-changing event exceptions might apply
Contact Social Security
- When you receive your IRMAA notice
- File Form SSA-44 if you have grounds for appeal
- Provide comprehensive documentation

Future Planning:

For future home purchases
- Consider the eventual sale and potential capital gains
- In high-appreciation markets like San Diego, this could be substantial
- Factor into retirement income planning
Review annually
- Two years before any planned major financial event
- Understand how it will affect Medicare premiums

The Broader Policy Issue

Many Medicare advocates argue that one-time capital gains from principal residence sales should qualify for IRMAA relief, as they don't represent ongoing income capacity. This is particularly relevant for:

Long-term homeowners in high-appreciation areas
Retirees downsizing (a financially responsible move)
People who lived in their homes for decades

Some members of Congress have proposed reforms, but as of 2025, the law remains unchanged.

Bottom Line for Prostate Cancer Patients

Given your specific situation with medical expenses and treatment considerations:

Factor IRMAA costs into your decision-making
- If selling your home to fund treatment or downsize
- Consider the $11,000+ spike in Medicare costs for one year
Explore all strategies with professionals
- Tax implications are complex
- Medicare cost is just one factor
- Your health needs and treatment access matter most
Don't let tax tail wag the dog
- If you need to sell for health, safety, or financial reasons, do it
- The IRMAA surcharge is temporary (one year)
- Your health and quality of life come first
Time the sale strategically if possible
- If you have flexibility, consider the 2-year lookback
- Coordinate with other financial planning

Sources and Additional Reading

Internal Revenue Service. (2024). "Publication 523: Selling Your Home." IRS.gov. https://www.irs.gov/publications/p523
Social Security Administration. (2025). "Medicare Premiums: Rules For Higher-Income Beneficiaries." SSA.gov. https://www.ssa.gov/benefits/medicare/medicare-premiums.html
Social Security Administration. (2025). "Form SSA-44: Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event." https://www.ssa.gov/forms/ssa-44.pdf
Centers for Medicare & Medicaid Services. (2025). "Medicare Costs." Medicare.gov. https://www.medicare.gov/your-medicare-costs
California State Board of Equalization. (2024). "Proposition 19 Implementation." BOE.ca.gov. https://www.boe.ca.gov/prop19/
Journal of Financial Planning. (2024). "IRMAA Planning Strategies for Medicare Beneficiaries." Journal of Financial Planning, Vol. 37, Issue 8.

Disclaimer: This information is for educational purposes. Tax and Medicare planning should be done with qualified professionals who understand your complete financial situation. Rules and thresholds change annually.

Sources and Citations

Centers for Medicare & Medicaid Services. (2025). "Medicare & You 2025." CMS.gov. https://www.medicare.gov/publications
Centers for Medicare & Medicaid Services. (2025). "2025 Medicare Parts A & B Premiums and Deductibles." CMS.gov. https://www.cms.gov/newsroom/fact-sheets/2025-medicare-parts-b-premiums-and-deductibles
U.S. Congress. (2022). "Inflation Reduction Act of 2022." Public Law 117-169. https://www.congress.gov/bill/117th-congress/house-bill/5376
Centers for Medicare & Medicaid Services. (2025). "Medicare Part D Out-of-Pocket Threshold." CMS.gov. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin
Social Security Administration. (2025). "Medicare Enrollment Periods." SSA.gov. https://www.ssa.gov/benefits/medicare/
California Department of Insurance. (2025). "Medigap Birthday Rule." CDI.ca.gov. https://www.insurance.ca.gov/01-consumers/110-health/60-resources/
Internal Revenue Service. (2025). "Health Savings Accounts and Medicare." IRS.gov. https://www.irs.gov/publications/p969
Medicare Rights Center. (2025). "Medicare Interactive: Understanding Medicare." MedicareInteractive.org. https://www.medicareinteractive.org/

Note: While this summary is based on the December 2025 presentation by licensed Medicare agent Rodney Shepard, Medicare rules and premiums change annually. Always verify current information with Medicare.gov or a licensed Medicare agent before making enrollment decisions.

Understanding Medicare: A Comprehensive Guide for Prostate Cancer Patients

Navigating Medicare - Rodney Shepherd

Introduction

Medicare Basics: Understanding the Parts

The Critical Decision: Medicare Advantage vs. Medicare Supplement

Medicare Supplement (Medigap) Plans

Medicare Advantage (Part C) Plans

What About PPO Medicare Advantage Plans?

Special Situations That Grant Guaranteed Issue Rights

Understanding Prescription Drug Coverage (Part D)

How the 25% Rule Protects You

Annual Plan Review is Critical

Enrollment Periods: When You Can Make Changes

IRMAA: The "Medicare Means Test"

The Late Enrollment Penalty Trap

Special Considerations for Prostate Cancer Patients

Choosing the Right Plan for Active Treatment

Active Surveillance Considerations

The "Birthday Rule" for Medigap Plans

Avoiding Medicare Scams

HSA Complications with Medicare

Recent Medicare Policy Changes and Updates

The Inflation Reduction Act's Impact (2025)

2026 Outlook

Federal Employee Health Benefits (FEHB) Considerations

Veterans Administration (VA) Benefits

Working Past 65: Special Rules

The Bottom Line: Key Recommendations

Additional Resources

Conclusion

Critical Medicare Issues for Our Members not discussed in the meeting.

SIDEBAR: Medicare Advantage and Advanced Prostate Cancer Treatment - A Growing Concern

The Promise vs. The Reality

The Prior Authorization Barrier

What This Means in Practice:

Real Problems Our Members Report

1. Denial of Advanced Radiopharmaceuticals

2. Specialist Access Restrictions

3. Advanced Imaging Denials

4. "Step Therapy" Requirements

5. Treatment Setting Restrictions

The Financial Incentive Problem

The Numbers Are Telling:

The "Equivalent Coverage" Myth

What Prostate Cancer Patients Should Know

Red Flags with Medicare Advantage Plans:

When Medicare Advantage Might Work:

The Difficult Trade-off

What You Can Do

If You're Already on Medicare Advantage:

If You're Approaching 65:

Advocacy Needed:

The Bottom Line

SIDEBAR: Medicare Advantage in San Diego County - What Prostate Cancer Patients Need to Know in 2026

The Dramatic Market Shift

1. Scripps Health's Complete Exit (2024)

2. UCSD Health's Severe Network Restrictions (2025-2026)

What This Means for Prostate Cancer Patients

The San Diego County Medicare Advantage Landscape for 2026

Specific Plan Considerations for Prostate Cancer Patients

Kaiser Permanente (Largest Enrollment)

Sharp Medicare Advantage (Second Largest)

SCAN Plans (Third Largest)

Blue Shield Plans

United Healthcare

The "Guaranteed Issue" Opportunity

Real Member Experiences

Special Needs Plans (C-SNPs)

Network Adequacy Concerns

What Our Support Group Members Should Do

The Uncomfortable Truth

Resources for San Diego Patients

SIDEBAR: Part D Prescription Drug Coverage for Prostate Cancer Patients - Critical Updates for 2026

The Good News: Major Improvements from the Inflation Reduction Act

The $2,100 Cap: A Game-Changer

The 25% Rule: Why Most Patients Never Hit the Cap

Important Exceptions: Generics Don't Count

Common Prostate Cancer Medications: 2026 Cost Considerations

ADT (Androgen Deprivation Therapy) Medications

AR Pathway Inhibitors (Advanced Disease)