The Donut Hole Is Gone in 2026, But Eliquis, Farxiga, and Symbicort Users Still See a $468 Swing Between Part D Plans
Voters Want Someone to Fix This. You Can Fix Your Piece of It Today.
Kaiser Family Foundation's health news desk recently profiled California's 22nd Congressional District — a toss-up seat where Rep. David Valadao and challenger Randy Villegas are both being pressed by voters to explain what they'll actually do about healthcare affordability. It's a good snapshot of where the country is right now: healthcare costs are the top-of-mind issue in a swing district, and voters are frustrated that nobody in Washington seems to have a fast answer.
Here's the thing about that frustration: while Congress debates, your Part D plan renewal doesn't wait for consensus. If you take Eliquis, Farxiga, and Symbicort, the difference between the right plan and the wrong one in your ZIP code is real money on a real bill this year — regardless of what happens in November. That math is knowable right now, and almost nobody runs it before Open Enrollment closes.
Whatever Happened to the Donut Hole?
If you've been on Medicare more than a few years, you probably still think in terms of the "donut hole" — the gap where you used to pay a lot more for drugs after your plan's initial coverage ran out, until you hit catastrophic coverage. That gap is gone. Since 2025, the Inflation Reduction Act redesigned Part D into three phases instead of four, and the middle "coverage gap" phase was folded into a single continuous benefit that ends the moment your true out-of-pocket spending (TrOOP — the running total of what counts toward your cap) hits $2,000.
So the jargon changed, but the confusion didn't disappear — it moved. The question isn't "when does the donut hole start" anymore. It's "how fast do I get to the $2,000 cap, and what do I pay along the way?" That path is entirely determined by which plan you're on, and it's where most of the dollar variation between plans now lives.
The Three Phases, Plainly
- Deductible phase: You pay 100% of your drug costs until you hit your plan's deductible. Based on Pelandri's plan-defaults dataset — the 30 CMS-published 2026 benefit design records we use as the baseline for every calculation on this site — the standard deductible sits at $615, though plans can set it anywhere from $0 to that ceiling.
- Initial coverage phase: After the deductible, you pay coinsurance or a fixed copay depending on your plan's formulary tier structure, until your TrOOP hits $2,000.
- Catastrophic phase: Once TrOOP hits $2,000, your cost-sharing for covered drugs drops to $0 for the rest of the calendar year.
That's it. No more 25%-then-5% donut hole math. But the deductible and initial coverage phases can still be built completely differently from plan to plan — and that's where your bill diverges.
Worked Example: Eliquis + Farxiga + Symbicort on Two 2026 Plans
Let's use a realistic three-drug list: Eliquis 5mg (brand blood thinner, roughly $560/month list price), Farxiga 10mg (now IRA-negotiated to roughly $178.50/month, as we detailed in our Eliquis and Farxiga negotiated-price comparison), and Symbicort (brand inhaler, roughly $241.50/month). That's about $980/month, or $11,760/year, in retail drug costs — more than enough to blow through the $2,000 cap on any plan.
Plan A — low premium, standard deductible: $8/month premium, $615 deductible, 25% coinsurance after that. Plan B — higher premium, no deductible: $47/month premium, $0 deductible, flat brand copays (roughly $170/month combined across the three drugs).
| Phase | Plan A ($8/mo premium) | Plan B ($47/mo premium) |
|---|---|---|
| Deductible paid | $615 (month 1) | $0 |
| Coinsurance/copay period | 25% of $980/mo | ~$170/mo flat |
| Month TrOOP hits $2,000 | Month 6 | Month 12 |
| Months at $0 drug cost | 6 | 0 |
| Total drug out-of-pocket | $2,000 | $2,000 |
| Annual premium | $96 | $564 |
| Total annual cost | $2,096 | $2,564 |
The two plans arrive at the exact same out-of-pocket drug ceiling — $2,000 — because both patients' costs are high enough to guarantee they'll reach catastrophic coverage eventually. The entire $468 annual difference comes down to premium. Plan A's member also gets six months of $0 drug costs, while Plan B's member is still paying flat copays into December. This is the same structural finding we walked through with a different drug trio in our Eliquis, Jardiance, and Entresto cap analysis — once your drug costs are high enough to guarantee catastrophic coverage, the deductible and coinsurance design almost stop mattering, and premium becomes the whole ballgame.
This is exactly the kind of phase-by-phase modeling Pelandri runs automatically for your specific drug list — so you're not manually tracking TrOOP across twelve months of Explanation of Benefits statements to figure out which plan wins.
The Manufacturer Discount Wrinkle Nobody Explains
Here's a detail that trips up even people who think they understand the $2,000 cap: TrOOP isn't just what you personally hand the pharmacist. For brand-name drugs like Eliquis and Symbicort that aren't yet subject to IRA price negotiation, manufacturers are required to provide a discount under the Manufacturer Discount Program, and that discount amount is credited toward your $2,000 TrOOP total — even though you never paid it out of your own pocket. Drugs that have already been negotiated under the IRA, like Farxiga, generally don't get this additional discount stacked on top, since the negotiated price is already the discount.
Practically, this means some beneficiaries reach catastrophic coverage having personally spent noticeably less than $2,000 in cash, because manufacturer credits filled part of the gap. It also means two plans with identical copay structures can put you at the cap on different calendar dates depending on how many of your drugs are brand-name-but-not-yet-negotiated versus already-negotiated. This is a detail buried deep in each plan's Evidence of Coverage document — not something you'll find on the plan's summary page, and exactly the kind of thing you can model for your specific situation at Pelandri instead of digging through PDFs.
When Your Drug List Never Reaches the Cap
Not everyone hits $2,000. If your drug list is generic and inexpensive, the deductible and copay design is the whole story — because you'll never trigger catastrophic coverage in the first place.
Take metformin ER, lisinopril, and atorvastatin — three of the most commonly prescribed generics in the country, as covered in our rosuvastatin and generic-vs-brand formulary breakdown. Combined retail cost: roughly $30/month, or $360/year — well under any plan's deductible.
| Plan C ($0 premium, $615 deductible) | Plan D ($35/mo premium, $0 deductible, $3 generic copay) | |
|---|---|---|
| Premium | $0 | $420 |
| Drug cost paid | $360 (full retail, never hits deductible) | $108 ($3 × 3 drugs × 12 months) |
| Total annual cost | $360 | $528 |
For this low-utilizer, Plan C — the plan with no premium at all — is $168 cheaper for the year, even though it offers zero drug coverage in practical terms, because the patient never spends enough to make the deductible relevant. Plan D's "convenient" $3 copay and $0 deductible sound appealing, but the $420 annual premium buys coverage this patient never needs. This is the mirror image of the high-cost example above: when your total drug spend can't reach the deductible, paying extra for a richer benefit design is money down the drain.
What MedPAC Is Watching for 2026–2027
None of this is static. The Medicare Payment Advisory Commission — the independent body that advises Congress on Medicare payment policy — just published its analytic agenda for the 2026–2027 meeting cycle, and Part D benefit redesign effects are squarely on it. MedPAC staff have also been presenting related research at AcademyHealth's Annual Research Meeting and the American Society of Health Economists conference, examining how the shift to the $2,000 cap is reshaping plan risk, premium-setting behavior, and low-income subsidy interactions.
Translation: the plan designs you're comparing this Open Enrollment aren't the final word. Insurers are actively adjusting premiums, deductibles, and formulary tier placement in response to the redesign — which is a big part of why a plan that was cheapest for your drug list last year may not be this year. MedPAC's own commentary on the 2024–2025 cycle flagged similar concerns about how plan sponsors respond to increased financial risk under the new benefit structure, and that response shows up directly in the premium and deductible numbers you're looking at right now.
Your ZIP Code, Pharmacy, and Income Still Move the Number
Every number above assumes a specific plan design — but plan designs vary sharply by geography. Pelandri's analysis of our census-acs-health-coverage dataset, which tracks 6,286 county-level coverage records, shows meaningful variation in how many Medicare beneficiaries in districts like California's 22nd carry supplemental coverage that buffers these cost swings versus those relying on Part D alone. Fewer buffers means the plan-selection math above isn't academic — it's the whole bill.
Income matters too. If you qualify for Extra Help (LIS), the deductible and coinsurance numbers above don't apply to you at all — you're on a fixed, low copay schedule regardless of plan, which we've broken down in detail for Xarelto and Farxiga users and Gabapentin and Letrozole users. And by comparison, our employer-plan-data set — 400 employer plan designs drawn from the KFF Employer Health Benefits Survey — shows average employer-sponsored out-of-pocket maximums running $2,000 to $4,000 for all medical costs combined, not just drugs. Medicare's $2,000 cap on prescriptions alone is, in that light, a genuinely strong benefit — but only if you're on the plan that gets you there without overpaying in premium along the way.
The Bottom Line
The donut hole terminology is gone, but the work of comparing plans isn't. For high-cost brand-drug lists, premium is now almost the entire decision once you know you'll hit the $2,000 cap. For low-cost generic lists, deductible and copay design still swings your bill by hundreds of dollars because you'll never get near that cap. You can't know which situation you're in — or which specific plan wins — without running your exact drug list, dosages, and pharmacy against every option in your ZIP code.
That's the calculation Pelandri was built to run. Enter your medications, and see the real phase-by-phase annual cost across every Part D plan available to you before Open Enrollment closes.
Sources
- In Toss-Up House District, Voters Crave Leadership To Fix Broken Healthcare — KFF Medicare
- MedPAC’s analytic agenda for the 2026-2027 meeting cycle — MedPAC
- Presentations by MedPAC staff at the 2026 AcademyHealth Annual Research Meeting and the 2026 Annual Conference of the American Society of Health Economists — MedPAC
- Presentations by MedPAC staff at the 2025 AcademyHealth Annual Research Meeting — MedPAC
- MedPAC’s analytic agenda for the 2024-2025 meeting cycle — MedPAC