Eliquis and Jardiance Cost $365 a Year With Extra Help vs. $2,100 Without It: What the New Medicaid Work Requirement Means for Your 2026 Part D Bill
The scenario nobody explains at your Medicaid renewal appointment
Here's a real situation playing out in county offices right now: you're a Medicare beneficiary who also qualifies for Medicaid — a "dual eligible" in program-speak. Because of that Medicaid enrollment, you were automatically given "deemed" status for Extra Help (the Low-Income Subsidy, or LIS), which caps what you pay for prescriptions like Eliquis (apixaban) 5mg and Jardiance (empagliflozin) 10mg at just a few dollars per fill.
Now a new federal Medicaid work requirement is rolling out, and KFF Health News' WAMU "Health Hub" segment on the rule laid out exactly how this plays out: more paperwork, more reporting deadlines, and more chances to lose Medicaid coverage over a missed form rather than a change in your actual eligibility. Lose full Medicaid, and you can lose your automatic Extra Help along with it — which means you'd have to reapply directly through the Social Security Administration, often with a gap where you're paying standard Part D cost-sharing instead of the LIS copay schedule.
That gap is not a rounding error. For a real three-drug list — apixaban, empagliflozin, and metformin — the swing between Extra Help and no Extra Help is $1,735 in a single year, based on Pelandri's modeling of CMS's 2026 Part D design parameters against our plan-defaults dataset of 30 benchmark plan structures. Let's walk through the actual numbers.
Your drug list, two cost-sharing worlds
Say you take:
- Metformin 1000mg (generic, Tier 1) — twice daily
- Eliquis (apixaban) 5mg (brand, Tier 3) — twice daily
- Jardiance (empagliflozin) 10mg (brand, Tier 3) — once daily
Under CMS's published 2026 Full LIS cost-sharing schedule, a full-subsidy Extra Help recipient pays no deductible, no premium (if enrolled in a benchmark plan), and fixed copays regardless of the drug's actual price: roughly $5.10 per generic fill and $12.65 per brand fill.
With Extra Help:
| Drug | Copay per fill | Fills/year | Annual cost |
|---|---|---|---|
| Metformin (generic) | $5.10 | 12 | $61.20 |
| Eliquis (brand) | $12.65 | 12 | $151.80 |
| Jardiance (brand) | $12.65 | 12 | $151.80 |
| Total | $364.80 |
Without Extra Help, you're on the standard 2026 Part D design: a deductible phase, an initial coverage phase with coinsurance, and a catastrophic phase that kicks in once your true out-of-pocket spending (TrOOP — the running total of what you've actually paid, not what the plan covered) hits Medicare's annual out-of-pocket cap. That cap, indexed under the Inflation Reduction Act's formula, sits at roughly $2,100 for 2026.
With list prices around $231/month for Eliquis (its IRA-negotiated price, as covered in our post on Eliquis now being a negotiated Medicare drug), roughly $482/month for Jardiance, and about $4/month for generic metformin, your combined annual drug spend before any coverage totals over $8,600. That's more than enough to blow through the deductible and the initial coverage phase and land you at the catastrophic threshold — meaning your out-of-pocket cost without Extra Help is the full $2,100 cap, not a penny less.
The swing: $2,100 − $365 = $1,735 per year, just from whether your Extra Help status stays active.
Why "deemed" status is the fragile part
Extra Help isn't one uniform program — there's a full subsidy and partial subsidy tier, and eligibility runs on income and asset limits reviewed annually. Dual eligibles get their Extra Help automatically "deemed" because Medicaid enrollment already proves they qualify. The problem the new work requirement creates is procedural, not financial: if a beneficiary's Medicaid case closes because a reporting deadline was missed — even temporarily — the deemed status can lapse too, and reinstating Extra Help requires a fresh application through Social Security rather than an automatic carryover.
Based on Pelandri's review of the census-acs-health-coverage dataset (drawn from the American Community Survey's geographic estimates across more than 6,000 areas), dual-eligible beneficiaries make up a meaningful share of Medicare enrollees in several states — in some cases over 18% of the Medicare population. That's not a small edge case; it's a large group of people whose Part D cost-sharing depends entirely on a Medicaid status that's about to get harder to maintain administratively.
MedPAC staff presented related research at the 2026 AcademyHealth Annual Research Meeting and the American Society of Health Economists conference this year specifically examining how coverage churn — beneficiaries cycling on and off Medicaid — affects medication adherence. The mechanics are simple: when the copay jumps from $12.65 to a coinsurance percentage of a $482 drug, people skip fills.
Even inside Extra Help, plan choice still moves your bill
Here's the part that surprises people: qualifying for Extra Help doesn't mean every Part D plan costs the same. Extra Help pays your premium in full only if you're enrolled in a plan at or below your region's "benchmark" premium. Enroll in a plan above benchmark, and you owe the difference out of pocket — every month, on top of your copays.
| Plan A (at benchmark) | Plan B (above benchmark) | |
|---|---|---|
| Monthly premium you owe | $0 | $38.40 |
| Annual premium cost | $0 | $460.80 |
| Copay total (same drug list) | $364.80 | $364.80 |
| Total annual cost | $364.80 | $825.60 |
That's a $460.80 difference between two plans, both technically "Extra Help plans," in the same ZIP code. This is exactly the kind of comparison that gets skipped when someone defaults to whatever plan they were auto-enrolled in years ago. Our plan-defaults dataset — covering 30 distinct plan benefit designs — and the broader cms-marketplace-plans dataset of 4,080 plan-year records show this benchmark gap is common, not rare, across regions.
This is the kind of analysis Pelandri runs for you — so you don't have to build the spreadsheet yourself, whether you're comparing benchmark plans under Extra Help or standard plans without it.
Translating the jargon on your Medicare mail
A few terms that show up on every plan document and mean nothing until someone explains them:
- TrOOP (True Out-of-Pocket costs): the running total of what you pay — deductible, copays, coinsurance — that counts toward the annual $2,100 cap. Manufacturer coupons generally don't count toward TrOOP; Extra Help copays do.
- Formulary tier: the pricing category a plan assigns each drug. Tier 1 is usually preferred generic (cheapest), Tier 3 or 4 is often brand-name, and specialty tiers can carry the highest coinsurance. The same drug can sit on different tiers on different plans.
- Catastrophic phase: once your TrOOP hits the annual cap, the plan covers 100% of your remaining costs for the rest of the year. Under the 2025 redesign, the old separate "donut hole" coverage gap phase was folded into this structure — there are now just three phases: deductible, initial coverage, catastrophic.
- IRMAA: an income-based premium surcharge added on top of your Part D (and Part B) premium for higher earners — unrelated to Extra Help, which works in the opposite income direction.
What to actually check before Open Enrollment closes
If you or a family member is a dual eligible affected by the new Medicaid work requirement, three things matter more than the premium sticker price:
- Confirm your Extra Help status is still active — not just your Medicaid status. A Medicaid lapse doesn't always trigger an immediate LIS lapse, but it can, and the notice often arrives after the fact.
- Check whether your plan is at or below the regional benchmark. As shown above, that alone can cost you $460 a year even with full Extra Help.
- Run your specific drug list, not a generic estimate. Eliquis and Jardiance are IRA-negotiated drugs now, but as we've covered in posts on Eliquis's negotiated price across plans and insulin caps versus real plan swings, the negotiated price doesn't erase plan-to-plan variation — it just moves where the variation shows up.
You can model this for your specific situation — your drug list, your ZIP code, your Extra Help status, and your preferred pharmacy — at Pelandri, rather than guessing based on last year's plan or a national average that doesn't apply to your prescriptions.
Healthcare affordability keeps showing up as a top voter concern in state elections this cycle, from California's gubernatorial race to Nevada's, according to KFF Health News' election coverage. But you don't need to wait for a policy outcome to fix your own numbers. The Extra Help and benchmark-plan mechanics described here are already locked in for 2026 — the only variable left is whether you check them before enrollment closes.
Sources
- In California Governor’s Race, Voters Face Stark Choice on Immigrant Healthcare — KFF Medicare
- New Medicaid Work Rule Means More Opportunities To Lose Coverage — KFF Medicare
- Presentations by MedPAC staff at the 2026 AcademyHealth Annual Research Meeting and the 2026 Annual Conference of the American Society of Health Economists — MedPAC
- Affordable Healthcare Emerges as a Voter Priority in Purple Nevada — KFF Medicare
- Journalists Discuss Healthcare Costs’ Political Fallout, Concerns About Canceled ICE Facility — KFF Medicare