Eliquis Costs $1,274 a Year on a $0-Premium Part D Plan vs. $972 on a $34/Month Plan: How Extra Help, Preferred Pharmacies, and Tier Exceptions Change Your Bill Before December 7
You take Eliquis (apixaban) 5 mg twice a day, metformin 500 mg, and atorvastatin 20 mg. Your current Part D plan has a $0 premium, and you have been on it for three years. Open Enrollment runs October 15 through December 7. Is staying put the cheap choice?
Below is the annual math for that exact drug list on two plans. Then we change three variables one at a time: your pharmacy, your income, and whether you ask for an exception. Each one can move the total by hundreds of dollars, which is why a general "best plan" answer can't work for you.
A note on the numbers. The plan designs below are illustrative. I built them to look like real 2026 plans, but they are not a specific insurer's offering. Your ZIP code will show different copays. The arithmetic and the structure are real, and you can reproduce them with your own plan documents.
Why a plan comparison matters more for people with several conditions
Two of this week's items point at the same problem from different angles.
The Medicare Rights Center summarized new KFF polling on adults with multiple or complex health conditions, including older Medicare beneficiaries. It found real access and affordability challenges for that group. That fits what counselors see. Someone on five or six medications has five or six chances for a plan to price a drug badly. Someone on one generic has almost none.
The Medicare Rights Center also reported on records from CMS's WISeR model. WISeR is a six-year model that started in January 2026 and applies AI-assisted prior authorization within Original Medicare. The records point to inappropriate denials of care. That is Part B territory, not Part D. But Part D plans already use the same kind of gatekeeping through prior authorization and step therapy (you must try a cheaper drug first). Those rules are buried in plan documents. They are one more reason to check your drugs against a plan's formulary before you enroll, not after a pharmacy counter surprise in January.
Health care costs are hitting everyone. KFF Health News reported on health care workers who chose to go uninsured after their premiums rose by hundreds of dollars a month. That is the ACA market, not Medicare. But it shows how a premium that looks manageable on paper can push people into bad decisions. Part D has its own version. A $0 premium looks safe, and the copays quietly cost more.
The worked example: three drugs, two plans
Here is the drug list and the assumptions.
- Eliquis 5 mg, twice daily. Medicare's negotiated price for Eliquis took effect in 2026 at $231 per month (30-day supply). Your cost share is based on that price.
- Metformin 500 mg, generic, Tier 1.
- Atorvastatin 20 mg, generic, Tier 1.
Two hypothetical plans:
| Feature | Plan A ($0 premium) | Plan B ($34/month premium) |
|---|---|---|
| Annual premium | $0 | $408 |
| Deductible | $615 (applies to Eliquis) | $0 |
| Eliquis after deductible | 25% coinsurance | $47 flat copay |
| Metformin (preferred pharmacy) | $5 | $0 |
| Atorvastatin (preferred pharmacy) | $5 | $0 |
The $615 is the 2026 standard maximum deductible. Some plans charge less, and some exempt Tier 1 and Tier 2 drugs, as Plan A does here.
Plan A, month by month
- Months 1 and 2: You pay the full $231 each month toward the deductible. That is $462.
- Month 3: $153 of deductible remains. You pay that, plus 25% of the remaining $78, which is $19.50. Total $172.50.
- Months 4 through 12: 25% of $231 is $57.75. Nine months comes to $519.75.
- Eliquis subtotal: $462 + $172.50 + $519.75 = $1,154.25.
- Generics: two drugs at $5 for 12 months = $120.
- Premium: $0.
Plan A total: $1,274.25.
Plan B, month by month
- Eliquis: $47 × 12 = $564
- Generics: $0
- Premium: $34 × 12 = $408
Plan B total: $972.
The $0-premium plan costs $302.25 more per year. The break-even math is simple. Plan B's premium costs $408 more, but its lower cost-sharing saves $710.25. The premium is a fee you pay to avoid the deductible and coinsurance.
This is the kind of side-by-side Pelandri runs for you, so you don't have to build the spreadsheet yourself.
Neither plan comes close to the annual out-of-pocket cap, which is $2,100 in 2026. That cap matters if you take several brand-name drugs, and I cover it in Medicare's $2,000 Drug Cap Explained: What Eliquis Users Actually Pay. For this list, though, your bill is decided by the deductible, the tier, and the copay, not the cap. A third of the money is in that deductible timing.
This pattern shows up repeatedly in comparisons like Eliquis and Jardiance Cost $1,584 a Year on a $38/Month Plan vs. $1,985 on a $0-Premium Plan. The cheapest premium is rarely the cheapest year.
Variable 1: Your pharmacy can swing the total by $720
Most Part D plans now have preferred pharmacies. These are in-network pharmacies that charge lower copays than standard in-network ones. Your plan's copay table has two columns, and the difference between them is real money.
Suppose Plan B's standard (non-preferred) retail pharmacy prices are:
- Eliquis: $95 per month
- Metformin and atorvastatin: $6 each
Plan B at a standard pharmacy:
- Eliquis: $95 × 12 = $1,140
- Generics: $6 × 2 × 12 = $144
- Premium: $408
Total: $1,692. That is $720 more than the same plan at a preferred pharmacy ($972).
The plan you pick can end up costing more than the "expensive" plan if your pharmacy isn't in its preferred network. Before you choose, look up whether your pharmacy is preferred, standard, or out of network for each plan you're considering. Chain pharmacies are in different networks from plan to plan. An independent pharmacy you trust may be preferred on one plan and not on another.
Mail order works the same way. Many plans offer a 90-day supply through mail order at a lower per-fill price, and sometimes at $0 for generics. Mail order isn't right for every drug. But if you take the same maintenance medications every month, ask each plan what a 90-day mail-order fill costs. I walked through this in Eliquis Costs $144/Year With Extra Help vs $2,000 Without It.
You can model your pharmacy against each plan's network at Pelandri, so the preferred-versus-standard gap shows up before you enroll.
Variable 2: Extra Help (LIS) changes the whole calculation
Extra Help, also called the Low-Income Subsidy (LIS), is a federal program that pays most of your Part D costs if your income and assets are below certain limits. The income limit is roughly 150% of the federal poverty level, which is about $23,000 to $24,000 for a single person. Asset limits also apply. Check the current figures at Social Security or your State Health Insurance Assistance Program (SHIP).
With full Extra Help in 2026:
- Your deductible is $0.
- You pay about $5 for a generic and about $12 to $13 for a brand-name drug (the exact figures are adjusted each year).
- In benchmark plans, your premium is fully or largely covered.
On the same drug list:
- Eliquis: about $12.65 × 12 = $151.80
- Metformin and atorvastatin: about $5.10 × 24 = $122.40
- Premium: $0 on a benchmark plan
Total: roughly $274 a year, compared with $972 to $1,692 without it.
Many eligible people never apply. If you're at all near the income limit, apply through Social Security or check your state's Medicare Savings Program, because qualifying for a Medicare Savings Program (MSP) automatically qualifies you for Extra Help. For a fuller walkthrough, see Eliquis, Jardiance, and Insulin Cost $1,715 Without Extra Help vs. $437 With It. Adult children helping a parent should read it too, because Extra Help can be applied for on someone's behalf with the right authorization.
Extra Help also lets you switch plans more often than the usual Open Enrollment window. But don't assume it fixes plan choice. Your copays are set by the program, but a plan that doesn't cover your drug is still a problem.
Variable 3: A tier exception can drop a drug's cost
Say your drug is on the formulary but at a high tier. Or a drug you need isn't covered at all, or requires step therapy you've already failed. You can ask your plan for an exception.
- A tier exception asks the plan to charge you the lower-tier copay for a drug.
- A formulary exception asks the plan to cover a drug that isn't on its list.
- Your prescriber must submit a supporting statement, usually explaining that the alternatives on the formulary would be less effective or harmful for you.
The plan must decide within 72 hours on a standard request, or 24 hours if your prescriber says waiting could seriously harm your health. If you're denied, you have the right to appeal.
Two things to know. First, exceptions are per plan and per year. An approval on your 2026 plan doesn't carry to a new plan for 2027, so factor the effort into a switch. Second, an exception doesn't apply if a drug is already on its lowest specialty tier in some cases. The plan's exceptions policy will say.
This matters most when a plan's rules change and you don't notice. If your medication suddenly costs $200 more per month, check whether the drug moved to a higher tier or now requires prior authorization.
What to do before December 7
Here is the checklist I'd give someone at my old desk at the Area Agency on Aging.
- Write down every drug, including dose and how often you take it. Include over-the-counter drugs your plan covers.
- Pick your pharmacy first, or two options. Then check whether each is preferred on the plans you're comparing.
- Run the total annual cost: premium + deductible + copays or coinsurance across all 12 months. Not just the premium.
- Check restrictions. Look for prior authorization, step therapy, or quantity limits on each of your drugs.
- Check Extra Help eligibility, even if you think you're over the line. Limits change each year, and some income doesn't count.
- Compare with Medicare Plan Finder, and confirm the results with the plan itself before enrolling.
The plan you choose during Open Enrollment applies January 1. After December 7, most people are locked in for the year.
A note on the data behind this analysis
Pelandri's data layer is 12,086 rows across six sources: aca-subsidy-params (210 rows), bls-medical-cpi (1,080), census-acs-health-coverage (6,286), cms-marketplace-plans (4,080), employer-plan-data (400), and plan-defaults (30). Those sources cover ACA marketplace, employer, and price-index data. They don't include Part D plan-level formularies, which is why I labeled the plan designs above as illustrative and did not attach dataset statistics to them. What the medical CPI and coverage data do support is the broader point: prices for care keep rising, and coverage decisions are made under real budget pressure. For actual Part D copays, use your plan's own documents and Medicare Plan Finder.
The bottom line
On this drug list, a $0-premium plan cost $302 more than a $34/month plan. Going to a standard pharmacy on the "cheaper" plan added another $720. Qualifying for Extra Help cut the bill to about $274. None of those results can be predicted from a premium, and none can be read off a headline. They depend on your drugs, your pharmacy, and your income.
If you want to see your own numbers, enter your medications and preferred pharmacy at Pelandri and compare plans for your ZIP code before Open Enrollment closes on December 7. It takes a few minutes, and it's the one decision each year that decides what your drugs cost.
This post is educational and not medical advice. Talk to your prescriber before changing any medication, and confirm plan details with the plan, Medicare Plan Finder, or your local SHIP counselor.
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
- Medicare Beneficiaries With Multiple and Complex Health Needs Face Challenges — Medicare Rights Center
- New Records Show Medicare WISeR AI Prior Authorization Model Causing Inappropriate Denials of Care — Medicare Rights Center
- Abortion Is on the Ballot Again as Post-Roe Policies Continue To Evolve — KFF Medicare
- Black Lung Disease Remains a Threat, but Federal Officials Delay Effort To Address It — KFF Medicare
- As Health Insurance Costs Soar, Healthcare Workers Also Feel the Pinch — KFF Medicare