$9,996 Drug Bill, $2,000 Out-of-Pocket Cap: What Eliquis and Entresto Users Actually Pay Across Three Part D Plans in 2026
$9,996 Drug Bill, $2,000 Out-of-Pocket Cap: What Eliquis and Entresto Users Actually Pay Across Three Part D Plans in 2026
Picture Margaret. She's 74, lives outside Albuquerque, and manages atrial fibrillation with Eliquis 5mg twice daily and heart failure with Entresto 49/51mg — plus metformin and amlodipine for diabetes and blood pressure. At retail, her four medications cost roughly $833 per month, or $9,996 per year.
Before 2025, Margaret would have faced a financial cliff called the coverage gap — the infamous "donut hole" — where she'd suddenly pay a much larger share of her drug costs after hitting a spending threshold. Since January 2025, that dynamic changed dramatically: a new $2,000 annual out-of-pocket cap (established by the Inflation Reduction Act) means Margaret's personal drug spending stops at $2,000, no matter how high her drug bills go.
But here's what most people miss: the $2,000 cap is a ceiling on what you spend, not a guarantee about which plan gets you there cheapest. Depending on Margaret's plan, premiums and cost-sharing structure can push her total annual cost anywhere from $2,000 to $2,624 — a $624 difference for identical prescriptions filled at the same pharmacy.
Let's work through the math.
How We Got Here: From the Donut Hole to the $2,000 Cap
When Medicare Part D launched in 2006, it included a coverage gap (the donut hole) that routinely cost beneficiaries thousands of dollars. After crossing an initial coverage limit, you were responsible for the full cost of your drugs until you hit a catastrophic threshold. For someone taking expensive brand-name medications, that gap could mean $3,000–$5,000 in sudden out-of-pocket costs in a single year.
The Affordable Care Act, now 16 years old as of this month, began closing that gap incrementally — first reducing brand-drug costs in the gap to 75%, then 70%, until the donut hole was fully closed in 2020. Beneficiaries still owed 25% in the gap phase, but the catastrophic threshold remained dangerously high.
The Inflation Reduction Act finished the job. Starting in 2025 and continuing into 2026, your true out-of-pocket cost for Part D drugs is capped at $2,000 per calendar year. Once you hit $2,000 in what Medicare calls TrOOP (True Out-of-Pocket costs), you pay $0 for covered drugs for the rest of the year.
That's genuinely historic. But "capped at $2,000" doesn't mean "costs $2,000 no matter what." It means your drug copays and coinsurance stop at $2,000 — premiums, however, keep running all 12 months.
The 2026 Part D Structure, in Plain English
Here's how the phases work for most standard Part D plans in 2026:
Phase 1 — Deductible: You pay 100% of your drug costs until you've spent $590 (the 2026 standard deductible). Some plans waive this entirely, especially for generics or preferred drugs.
Phase 2 — Initial Coverage: After the deductible, you pay your plan's copay or coinsurance on each drug. This continues until your TrOOP hits $2,000.
Phase 3 — Catastrophic: Once your TrOOP reaches $2,000, you pay $0 for covered drugs for the rest of the calendar year. (Note: manufacturer discounts on brand-name drugs count toward TrOOP even though you didn't pay them yourself — this accelerates how quickly you reach the cap.)
Your monthly premium does not count toward TrOOP. It runs all year, regardless of which phase you're in.
Margaret's Drug List and Three Real-World Plan Scenarios
Here's what Margaret takes each month, and the cost structure under three illustrative Part D plans available in her region:
| Drug | Monthly Retail Price | Plan A Tier | Plan B Tier | Plan C Tier |
|---|---|---|---|---|
| Eliquis 5mg (60 tabs) | $231 | Tier 4, 40% | Tier 3, 25% | Tier 3, 20% |
| Entresto 49/51mg (60 tabs) | $590 | Tier 4, 40% | Tier 3, 25% | Tier 4, 33% |
| Metformin 1000mg | $8 | Tier 1, $0 | Tier 1, $3 | Tier 1, $0 |
| Amlodipine 10mg | $4 | Tier 1, $0 | Tier 1, $3 | Tier 1, $0 |
| Monthly premium | — | $0 | $32 | $52 |
| Annual deductible | — | $590 | $0 | $590 |
Note: Eliquis pricing reflects its 2026 IRA Maximum Fair Price of $231/month. Entresto remains non-negotiated in 2026. All plan cost-sharing figures are illustrative, based on CMS Medicare Plan Finder tier structures in comparable markets.
The Annual Cost Calculation: Month by Month
Plan A — $0 Premium, $590 Deductible, 40% Coinsurance on Brand Drugs
Margaret's expensive brand drugs (Eliquis + Entresto = $821/month) mean she blows through the $590 deductible in month one. Here's the TrOOP accumulation:
- Month 1: Pays $590 deductible (exhausted mid-month), then 40% × remaining brand costs ≈ $97. Month 1 total: $687. TrOOP: $687.
- Months 2–4: 40% × $821 = $328/month in brand coinsurance. TrOOP after month 4: $687 + (3 × $328) = $1,671.
- Month 5: Needs $329 more to hit $2,000 cap. At $328/month, she crosses $2,000 in early May.
Annual totals for Plan A:
- Drug out-of-pocket: $2,000 (cap reached in May)
- Premiums: $0
- Total: $2,000
After May, Margaret pays $0 per month for her drugs through December — seven months of free prescriptions.
Plan B — $32/Month Premium, $0 Deductible, 25% Coinsurance on Brand Drugs
No deductible means Margaret starts accumulating TrOOP immediately at a lower coinsurance rate:
- Monthly brand coinsurance: 25% × $821 = $205.25
- Generic copays: $3 × 2 drugs = $6/month
- Monthly TrOOP: $211.25
- Time to hit $2,000 cap: $2,000 ÷ $211.25 = 9.5 months — hits cap in mid-October
Annual totals for Plan B:
- Drug out-of-pocket: $2,000 (cap reached in October)
- Premiums: $32 × 12 = $384
- Total: $2,384
Plan C — $52/Month Premium, $590 Deductible, Mixed Coinsurance
Plan C's lower coinsurance on Eliquis (20%) but higher on Entresto (33%) creates a middle path:
- After deductible exhausted in month 1, monthly costs: 20% × $231 + 33% × $590 = $46 + $195 = $241/month
- Starting TrOOP after month 1: ~$660
- Time to hit $2,000 from there: $1,340 ÷ $241 = 5.6 more months → cap hit around late June or early July
Annual totals for Plan C:
- Drug out-of-pocket: $2,000
- Premiums: $52 × 12 = $624
- Total: $2,624
The Counterintuitive Insight: Higher Coinsurance Can Still Win
Here's what this math reveals that most plan comparison tools obscure:
When you take expensive enough drugs to hit the $2,000 cap, coinsurance structure matters less than you think. All three plans get Margaret to $2,000 in out-of-pocket drug costs. What separates them is premiums — and that's where Plan A ($0 premium) wins by $384 over Plan B and $624 over Plan C.
The plan with the highest coinsurance rates (40% on Plan A) is actually the cheapest annual option because Margaret hits the cap in May either way, and she pays $0 from June through December regardless.
But this logic inverts completely if you don't take expensive enough drugs to hit the cap. We explored this dynamic in depth for Eliquis users specifically — and it changes the entire plan ranking.
Take a beneficiary on only Eliquis ($231/month) plus a few cheap generics. Their monthly TrOOP on Plan A (40% on Eliquis) is about $92. Over 12 months that's $1,104 — they never hit the cap. On Plan B (25% coinsurance, no deductible), their monthly TrOOP is about $58 — $693 annually, plus $384 in premiums = $1,077 total. Plan B is suddenly $27 cheaper, and the gap widens further for lower-cost drug lists.
The IRA's negotiated pricing on Eliquis already changed the math for millions of beneficiaries. Adding a second expensive drug like Entresto shifts the optimal plan again. There is no universal "best" plan — only the best plan for your drug list.
This is exactly the kind of analysis Pelandri runs for you — modeling TrOOP accumulation, cap timing, and total annual cost across every plan in your ZIP code, for your specific medications.
The Cap Timing Effect: July Beats October
A detail worth flagging: the month you hit the $2,000 cap determines how many months of free prescriptions you receive.
Plan A gets Margaret to $0 copays in May — seven months free. Plan C gets her there in late June — six months free. Plan B gets her there in October — two months free.
When you're managing a condition like heart failure or afib, those free months aren't abstract. They're months where you fill Eliquis and Entresto without a second thought about cost. For a caregiver managing a parent's prescriptions, knowing the cap will be hit by summer is planning information — it affects whether you stock up before January, whether you use mail order for 90-day supplies, and how you budget the second half of the year.
If you also receive Extra Help (the Low Income Subsidy) from Medicare, your cost-sharing is different from the scenarios above, and the $2,000 cap may function differently for you. The Extra Help and preferred pharmacy tier dynamics for Eliquis users deserve their own calculation — and they're worth running before you assume your current plan is optimal.
Open Enrollment Ends March 31 — This Is the Last Window Until October
The Medicare Advantage and Part D Open Enrollment Period runs through March 31, 2026. After that, you cannot switch plans until October's Annual Enrollment Period, which takes effect January 1, 2027. If Margaret is on Plan C right now, she's leaving $624 on the table compared to Plan A — and she has until the end of this month to fix it.
Most beneficiaries default to last year's plan. CMS data consistently shows that fewer than 10% of Medicare beneficiaries switch Part D plans during Open Enrollment, even when better options are available. The Medicare Rights Center, in its recent review of ACA protections, noted that beneficiaries who actively compare plans capture substantially more of the law's financial protections than those who auto-renew.
The right comparison isn't premium vs. premium. It's total annual cost: premium + deductible + copays through TrOOP + whether you hit the $2,000 cap and when. Those variables interact differently for every person's drug list.
You can run this exact calculation for your specific medications at Pelandri. Enter your drugs, your pharmacy, your ZIP code — and see the full annual cost across every plan available to you, including which month you'd hit the $2,000 cap on each option.
The deadline is March 31. If your drug list includes even one expensive brand medication, the difference between the right plan and the wrong one is measured in hundreds of dollars — and in months of free prescriptions you either get or don't.
Sources
- Sixteen Years of the Affordable Care Act — Medicare Rights Center
- How the Trump Administration Uses Migrant Kids To Find and Detain Family Members — KFF Medicare
- Give and Take: Federal Rural Health Funding Could Trigger Service Cuts — KFF Medicare
- Trump Team Claims Successes Against ACA Fraud While Pushing for More Controls — KFF Medicare
- An Arm and a Leg: Steep Health Care Costs Steer Americans to Tough Decisions — KFF Medicare