Entresto and Jardiance Cost $2,033 a Year on a $0-Premium Part D Plan vs. $1,560 on a $31/Month Plan: How the $2,100 Out-of-Pocket Cap Changes the Answer Before December 7
Here is a drug list I would hand to any adult child helping a parent this fall: Entresto 49/51 mg twice daily, Jardiance 10 mg once daily, memantine 10 mg twice daily, donepezil 10 mg at bedtime, and metoprolol succinate 50 mg daily. It belongs to "Ruth," a composite 76-year-old in a rural Minnesota ZIP code. On one illustrative Part D plan with a $0 premium, her year costs $2,033. On a plan with a $31 monthly premium, it costs $1,560. Then a prescriber adds one $650-a-month brand-name drug, and the $0-premium plan becomes the cheaper one.
That flip is why "which plan is cheapest?" has no answer until you plug in your own drugs. Open Enrollment runs October 15 to December 7. Your plan's Annual Notice of Change was due in your mailbox by September 30, which is today. Read it before you let the plan renew on autopilot.
What This Week's Five Stories Have in Common
The five pieces we read this week look unrelated. They all come back to the same drug bill.
- Medicare Rights Center summarized new KFF polling on adults with multiple or complex health conditions, including older Medicare beneficiaries. The poll points to access and affordability challenges. That is Ruth: more drugs means more ways for plan rules to interact.
- KFF Health News reported on a KFF–Associated Press survey finding that rural residents say national health initiatives haven't reached their communities. I'll stay out of the politics. The practical point is that in a rural ZIP, what reaches you is the plan you pick and the pharmacy you can get to.
- KFF Health News also covered sedating drugs for people with dementia, including a Michigan family's clash over what belongs on a medication list. Those decisions belong to patients, guardians, and prescribers. This post prices lists. It doesn't recommend them.
- The nursing home flood-risk analysis describes staff in New Richland, Minnesota, evacuating 36 residents. It is one of 100 facilities KFF Health News flagged. An evacuation means a new address, often a new pharmacy, sometimes a new plan.
- KFF Health News on Medicaid eligibility changes taking effect October 1 cites a CBO estimate of 100,000 more uninsured immigrants by 2034. Medicaid is one door to automatic Extra Help, so losing it can change a drug bill.
I'll return to each in the practical section below.
The Donut Hole Is Gone. Here Is What Replaced It.
Many people still ask, "When does the donut hole kick in for my drugs?" The coverage gap phase was eliminated starting in 2025. The question now is which month you hit the out-of-pocket cap.
You will still see "the $2,000 cap" everywhere. That was the 2025 number. For 2026 it is $2,100, and CMS indexes it upward each year, so 2027 is higher. Confirm your plan's exact 2027 figures on Medicare Plan Finder.
| Phase | 2026 rule | What you pay |
|---|---|---|
| Deductible | Up to $615 (plans can charge less, or skip it for some tiers) | 100% of the drug's cost until you meet it |
| Initial coverage | Set by your plan's tiers | Copays or coinsurance (often 25%) |
| Coverage gap ("donut hole") | Eliminated | Nothing separate |
| Out-of-pocket cap | $2,100 | The ceiling on your cost-sharing |
| Catastrophic | After you hit the cap | $0 for covered drugs through December 31 |
The running total Medicare counts toward the cap is called TrOOP (true out-of-pocket). It includes deductibles, copays, and coinsurance you pay. It also includes what Extra Help pays for you. It does not include your monthly premium, drugs your plan doesn't cover, or coupon and cash-price purchases made outside your plan. That last exclusion trips people up, and we covered it in why pharmacy coupons don't count toward Medicare's cap.
Worked Example: Ruth's List on Two Plans
Where these numbers come from. Pelandri's data layer holds 12,086 rows across six sources: aca-subsidy-params, bls-medical-cpi, census-acs-health-coverage, cms-marketplace-plans, employer-plan-data, and plan-defaults. None of them is a Part D formulary file, so I did not pull a real plan contract for this example. I used the published 2026 Part D parameters and CMS's negotiated prices. Both plans below are illustrative designs. The bls-medical-cpi series (1,080 rows, BLS series CUUR0000SAM) is a reminder that medical prices move, so treat every dollar figure here, mine included, as a snapshot.
Ruth's drugs (30-day supply):
| Drug | Price the plan pays | Tier |
|---|---|---|
| Entresto 49/51 mg | $295 (CMS negotiated price, 2026) | 3 |
| Jardiance 10 mg | $197 (CMS negotiated price, 2026) | 3 |
| Memantine 10 mg | Generic | 2 |
| Donepezil 10 mg | Generic | 1 |
| Metoprolol succinate 50 mg | Generic | 1 |
The two plans:
| Plan A | Plan B | |
|---|---|---|
| Monthly premium | $0 | $31 ($372/year) |
| Deductible | $615 on Tiers 3–5 | $0 |
| Tier 1 generics | $0 | $0 |
| Tier 2 generics | $8 | $5 |
| Tier 3 brands | 25% coinsurance | $47 flat |
Plan A, step by step. The two brands total $492 a month, or $5,904 a year.
- Ruth pays the $615 deductible first.
- She then pays 25% of the remaining $5,289, which is $1,322.
- That makes $1,937 for the two brands.
- Memantine at $8 a month adds $96.
Plan B, step by step. Two brands at $47 flat is $94 a month, or $1,128 a year. Memantine at $5 adds $60.
| Annual cost | Plan A | Plan B |
|---|---|---|
| Entresto + Jardiance | $1,937 | $1,128 |
| Memantine | $96 | $60 |
| Donepezil, metoprolol | $0 | $0 |
| Premiums | $0 | $372 |
| Total | $2,033 | $1,560 |
Plan B wins by $473. The break-even is simple. Plan B saves $845 in cost-sharing ($2,033 minus $1,188), so it stays cheaper as long as its premium is under about $70 a month higher than Plan A's. The "$0 premium" headline hides $845 of extra counter costs.
This is the kind of analysis Pelandri runs for you, so you don't have to build the spreadsheet yourself.
When a Third Brand Drug Arrives: Finding Your Cap Month
Now suppose a prescriber adds a hypothetical brand drug at $650 a month, about what a once-daily maintenance inhaler runs. Ruth's brand total becomes $1,142 a month.
On Plan A, she pays the deductible, then 25%. Memantine's $8 is included:
| Month | You pay | Running total |
|---|---|---|
| January | $755 | $755 |
| February | $294 | $1,048 |
| March | $294 | $1,342 |
| April | $294 | $1,635 |
| May | $294 | $1,929 |
| June | $171 | $2,100 (cap reached) |
| July–December | $0 | $2,100 |
Plan A's full-year cost-sharing is $2,100, with a $0 premium. Everything after June is the catastrophic phase, at $0.
On Plan B, the flat copays never reach the cap, so the premium stacks on top:
- New drug on Tier 3 ($47): ($141 brands + $5 memantine) × 12 = $1,752, plus $372 in premiums = $2,124.
- New drug on Tier 4 ($95): ($47 + $47 + $95 + $5) × 12 = $2,328, plus $372 = $2,700.
| Scenario | Plan A | Plan B |
|---|---|---|
| Two brands | $2,033 | $1,560 |
| Three brands, new drug on Tier 3 | $2,100 | $2,124 |
| Three brands, new drug on Tier 4 | $2,100 | $2,700 |
The pattern is that a coinsurance plan has a ceiling and a flat-copay plan may not. If your list could grow, or already includes several expensive brands, how the plan prices Tier 4 matters as much as the premium. If the new drug were a cheap generic, Ruth's numbers would look like the two-brand case and the cap would never come into play.
One more piece of timing math: Plan A's $755 January bill is hard on a fixed income even though the year's total is capped. The Medicare Prescription Payment Plan lets you spread cost-sharing across monthly bills. If Ruth opts in for January, her maximum monthly payment is $175, which is $2,100 divided by 12. It doesn't reduce what she owes. It smooths the cash flow. For more on cap timing with expensive brands, see what Eliquis and Entresto users actually pay across three Part D plans.
You can model this for your specific list, and see which month you'd hit the cap, at Pelandri.
Four Situations From This Week's News That Change Your Numbers
1. You live in a rural ZIP. Plans price the same drug differently depending on whether you use a preferred pharmacy, and the nearest preferred one can be a long drive. Mail order may be your best lever. Check the pharmacy network tab in Plan Finder, not just the premium. Insurer-owned pharmacies can also change your cost, as we showed in how vertical integration changes your Part D bill.
2. A family member's medication list changes mid-year. For dementia-related prescribing, Medicare requires Part D plans to cover all or substantially all drugs in six "protected" classes, and antipsychotics are one of them. Coverage is not the same as cost, though. The tier, prior authorization, and quantity limits can still differ by plan. If a prescriber adds a drug that lands on a high tier, you or a guardian can ask the plan for a tier exception, which needs a prescriber's supporting statement. For the cost side of memory-care generics and brands, see generic donepezil vs. brand Aricept under the Part D cap.
3. A parent moves, or has to be moved. The flood-risk reporting is a reminder that nursing home residents can relocate on short notice. People who move into, live in, or move out of an institution may qualify for a Special Enrollment Period that lets them change Part D plans outside Open Enrollment. People affected by a FEMA-declared disaster may qualify for one too. A facility's long-term-care pharmacy also has to be in your plan's network. Ask the plan before the move if you can.
4. Medicaid coverage is ending for you or a relative. If Medicaid or a Medicare Savings Program gave you automatic Extra Help (the Low-Income Subsidy), losing that eligibility can end the automatic status. Extra Help caps copays at roughly $5 for generics and under $13 for brand drugs in 2026, so the difference is large. Check your status with Social Security or your State Health Insurance Assistance Program (SHIP), and apply directly if you qualify on income (up to 150% of the federal poverty level). We walked through this in Eliquis and Jardiance costs with and without Extra Help.
Your Checklist Before December 7
- Read the Annual Notice of Change your plan mailed. Look for tier changes and new deductibles on your drugs specifically.
- Write down every drug with its dose and quantity: brand or generic, how many pills, how often.
- Name your pharmacy, including mail order if you use it. Enter it in Plan Finder.
- Compare total annual cost, not premiums. Use the 2027 plan data in Plan Finder.
- Find your cap month. If the plan estimates your cap arrives in June, your second-half costs are $0 and the premium is what's left to compare.
- Check prior authorization and step therapy for each brand drug. A plan that covers the drug but requires a hurdle may not be the plan you want.
- Switch by December 7 for January 1 coverage.
If you want this for your own list, Pelandri compares plans drug by drug and dollar by dollar, including deductible, coinsurance, tier placement, and the month you'd reach the cap. The KFF polling on people with multiple conditions points to the same conclusion: the more drugs you take, the more a wrong plan choice costs you. Put your actual medications in, and pick your plan before Open Enrollment closes.
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
- Rural MAHA Followers Say Trump Health Policies Haven’t Reached Their Communities — KFF Medicare
- Drugs Are Widely Used To Sedate Dementia Patients. Her Sons Wanted To Keep Her Off Them. — KFF Medicare
- These 100 Nursing Homes Face Perilous Flood Risk. Minnesota Shows What Can Happen. — KFF Medicare
- US Poised To Boot Legal Immigrants From Medicaid, Including Refugees and Sex-Trafficking Victims — KFF Medicare
- Medicare Beneficiaries With Multiple and Complex Health Needs Face Challenges — Medicare Rights Center