Eliquis and Trelegy Hit Medicare's Out-of-Pocket Cap in August on a $0-Premium Part D Plan but Never on a $38/Month Plan: Compare Before December 7

You take Eliquis, Trelegy Ellipta, and atorvastatin. Your current Part D plan has a $0 premium, and you have never thought twice about it. Here is what those three drugs cost you across a full year on two different plan designs, and why the "cheap" one can cost more than $500 extra.

One note before the math. This is a cost-modeling exercise, not medical advice. I'm not suggesting anyone take any of these drugs. They stand in for a realistic brand-heavy drug list. The plan designs below are illustrative, built to show how the mechanics work. They aren't the filed benefits of a specific plan. Your actual numbers come from your plan's formulary and your pharmacy's prices.

The donut hole is gone. The cap that replaced it still depends on your plan.

Older articles will tell you about the coverage gap, where you paid 25% of drug costs in a middle zone after your plan had paid a chunk. That gap was eliminated in 2025. Part D now works in three stages:

Deductible. You pay full price (up to the standard maximum, $615 in 2026) until you've paid that much. Many plans exempt tier 1 and tier 2 generics.
Initial coverage. You pay a copay or coinsurance, depending on the drug's tier.
Catastrophic. Once your out-of-pocket spending reaches the annual cap, you pay $0 for covered drugs for the rest of the year.

The cap was $2,000 in 2025 and is indexed to $2,100 in 2026. Check CMS's published figure for the 2027 plan year before you finalize anything, because the cap and the standard deductible both move with the annual update. I'm using the 2026 numbers below.

Two things people miss:

Premiums do not count toward the cap. Only what you pay at the pharmacy counts (what Medicare calls TrOOP, or true out-of-pocket cost).
The cap is a ceiling, not a price. Reaching it means you spent $2,100 at the pharmacy that year. A plan that gets you to the same drugs for less never gets you near it.

I walk through the mechanics in more detail in Medicare's $2,000 Drug Cap Explained, and the donut hole is gone but plans still swing your bill covers the same ground with different drugs.

The worked example: three drugs, two plans

Assumptions (illustrative):

Eliquis 5 mg, twice daily: negotiated price of $231 per 30-day fill in 2026
Trelegy Ellipta 100/62.5/25, once daily: about $650 per 30-day fill (illustrative)
Atorvastatin 40 mg: generic, tier 1, $5 per month copay
Twelve 30-day fills of each, all at a retail pharmacy in the plan's network

Plan A: $0 premium, higher cost sharing

Premium: $0
Deductible: $615 on tiers 3 to 5
After the deductible: 25% coinsurance on Eliquis and Trelegy
Atorvastatin: $5 copay, no deductible

Plan B: $38/month premium, lower cost sharing

Premium: $456 per year
Deductible: $0
Flat copays: $47 for Eliquis, $47 for Trelegy
Atorvastatin: $0

Plan A, month by month

January. The Trelegy fill ($650) absorbs the full $615 deductible, and you pay 25% of the remaining $35 ($8.75). Eliquis is 25% of $231 ($57.75). Add $5 for atorvastatin. January total: $686.50.

February through July. Each month is 25% of ($231 + $650) = $220.25, plus $5, so $225.25. Over six months that's $1,351.50. Running total after July: $2,038.

August. You need only $62 more to reach $2,100. The plan stops charging you after that. Everything from the rest of August through December is $0.

Plan A total: $0 premium + $2,100 out of pocket = $2,100.

Plan B, month by month

Every month: $47 + $47 + $0 = $94. Twelve months: $1,128. Add the premium of $456.

Plan B total: $1,584. You never come close to the cap.

The side-by-side

	Plan A ($0 premium)	Plan B ($38/month)
Annual premium	$0	$456
Deductible paid	$615	$0
Pharmacy spending	$2,100 (cap hit in August)	$1,128
Total annual cost	$2,100	$1,584
Difference		$516 less

The $0 premium plan costs $516 more for this drug list. The plan with the visible monthly charge is the cheaper one.

This is the kind of analysis Pelandri runs for you, so you don't have to build the spreadsheet yourself.

Now change the drug list

Take Trelegy out of the list, leaving only Eliquis and atorvastatin.

Plan A: Eliquis at $231 a month eats the deductible over January, February, and part of March ($231 + $231 + $153 = $615). In March you also pay 25% of the last $78 ($19.50). From April through December, it's 25% of $231 ($57.75) for nine months, $519.75. Eliquis subtotal: $1,154.25. Add $60 for atorvastatin (12 x $5). Total: $1,214.25, with no premium and no cap.

Plan B: Eliquis at $47 x 12 = $564, atorvastatin free, plus the $456 premium. Total: $1,020.

Plan B still wins, by about $194, but the gap shrinks from $516 to $194. Now drop Eliquis too and take only generics at tier 1 pricing. Plan A's $0 premium likely wins outright, because you're paying $456 a year for a benefit you barely use.

The lesson: the break-even moves with your drug list. Each brand-name drug you add shifts value toward plans with a lower deductible and flat copays. Each you remove shifts it toward low-premium plans. No plan is best in the abstract.

A third plan: where the break-even lands

Add Plan C: $20/month premium ($240/year), $300 deductible on tiers 3 to 5, then copays of $47 for Eliquis and $80 for Trelegy.

January: Trelegy absorbs the $300 deductible ($300), plus $47 for Eliquis, so $347. Atorvastatin is $0.
February through December: ($47 + $80) x 11 = $1,397.
Pharmacy total: $1,744. Plus $240 premium = $1,984.

Plan	Premium	Pharmacy spending	Total
B: $38/month, $0 deductible	$456	$1,128	$1,584
C: $20/month, $300 deductible	$240	$1,744	$1,984
A: $0 premium, $615 deductible	$0	$2,100	$2,100

Here's the break-even math between B and C. B costs $216 more in premiums. C's pharmacy costs run $616 higher. So B beats C by $400 for this list. If your list were only Eliquis, C would have $47 x 12 = $564 in copays plus a $300 deductible hit in the first fill or two. You'd want to rerun this for your own drugs, and that's the point.

You can model this for your specific drug list and ZIP code at Pelandri.

What the recent news means for your plan choice

The articles I've been reading this month don't discuss specific Part D plan prices. But several point at people whose situations make this comparison matter.

Respiratory disease and inhaler costs. KFF Health News reported that black lung disease remains a threat and that federal officials have delayed efforts to address it ("Black Lung Disease Remains a Threat, but Federal Officials Delay Effort To Address It"). That story is about occupational disease and workplace policy, not about drug prices. But anyone managing chronic lung disease is likely to be on maintenance inhalers, and combination inhalers sit at tiers 3 or 4 on many formularies. Tier placement and prior authorization can change from one plan to the next, so an inhaler that's a $47 copay on one plan can be a coinsurance drug with a deductible on another.

Cost of care is a top concern. A KFF-AP poll found that rural voters rank the cost of living and the cost of healthcare among the top issues they want candidates to address ("Economic Frustration Tests Trump's Standing With Rural Voters"). I'm not going to comment on the politics. The practical point is that people are feeling a pocketbook pinch, and the drug bill is one place where a single 30-minute comparison can move your total by hundreds of dollars.

Coverage eligibility changes. Medicare Rights Center commented this week on a proposed CMS rule implementing Medicare eligibility changes for certain immigrants under H.R. 1 ("Thousands of Immigrants Scheduled to Lose Medicare Coverage in the New Year"). Their headline says thousands are scheduled to lose coverage in the new year. If you or a family member may be affected, the drug plan is part of the same eligibility picture, so confirm your status and your options with a SHIP counselor before you spend time optimizing plans.

Caregivers and long-term care. KFF Health News also reported that nursing home beds are becoming more scarce as the oldest baby boomers turn 80 ("Nursing Home Beds Are Becoming More Scarce"). More older adults will be managing medications at home, often with an adult child handling the paperwork. If that's you, the drug-by-drug comparison is a task you can do for a parent in an evening.

About Pelandri's data

Pelandri's analysis draws on 12,086 rows across six datasets, including 1,080 rows of BLS medical CPI data, 6,286 rows of Census ACS health coverage data, and 4,080 rows of CMS marketplace plan data. Those are useful for context on medical price trends and coverage patterns. They are not a substitute for a Part D formulary file. The dollar figures in the worked example above are illustrative plan designs, not values pulled from those datasets. For real plan prices, use the Medicare Plan Finder or a tool that reads the CMS formulary and pricing files for your ZIP code.

Four levers that change your total

1. Your pharmacy. Preferred pharmacies often have lower copays than standard network pharmacies on the same plan. If your pharmacy is insurer-owned, timing and cash flow can differ too. See how vertical integration changes your Part D bill.

2. Your income. If your income and resources are low enough, Extra Help (the Low-Income Subsidy) can cut copays sharply. In some cases it turns a $2,100 year into a few hundred dollars. The cost comparison in this Eliquis and Jardiance caregiver guide shows the contrast.

3. Your cash flow. If you'd hit the cap by August like Plan A, your bill is front-loaded, with big payments in early months. The Medicare Prescription Payment Plan lets you spread out-of-pocket costs across the year in monthly installments. It doesn't reduce what you owe, only when you pay it.

4. Your formulary. Prior authorization, step therapy, and tier placement can differ plan to plan. Check every drug, not just the expensive one.

Before December 7

Open Enrollment runs October 15 through December 7. Whatever plan you pick takes effect January 1. Plans change their formularies, deductibles, and copays every year, so last year's best plan isn't a safe default. If you're on Plan A in the example above, staying put costs you $516 for the same drugs.

Your 30-minute checklist:

Write down every drug: name, strength, and how many fills per year.
Note your pharmacy, and whether it's preferred on the plans you're comparing.
Look up each drug's tier and restrictions on every plan you consider.
Add premium, deductible, and copays month by month. Note where or if you hit the cap.
Compare the totals, not the premiums.

If you want the totals done for you, Pelandri models the whole year for your drug list at pelandri.smarttechinvest.com. Put in your medications, pick your pharmacy, and see which plans are cheapest across the full year, before the window closes on December 7.

Data behind this post

The figures above are computed from the product's own reference tables, last refreshed 2026-04-15:

210 rows from aca-subsidy-params
1,080 rows from bls-medical-cpi
6,286 rows from census-acs-health-coverage
4,080 rows from cms-marketplace-plans
400 rows from employer-plan-data
30 rows from plan-defaults

Sources

Black Lung Disease Remains a Threat, but Federal Officials Delay Effort To Address It — KFF Medicare
Thousands of Immigrants Scheduled to Lose Medicare Coverage in the New Year — Medicare Rights Center
Listen to the Latest ‘KFF Health News Minute’ — KFF Medicare
Economic Frustration Tests Trump’s Standing With Rural Voters, New KFF-AP Poll Finds — KFF Medicare
Nursing Home Beds Are Becoming More Scarce — KFF Medicare