Insulin Capped at $35, Eliquis Negotiated to $231/Month: Why Your Part D Plan Choice Still Swings Your Bill by $500+ in 2026

The scenario: you did everything right, and your plan still cost you $512 extra

You take Eliquis 5mg twice daily, Jardiance 10mg once daily, and long-acting insulin. On paper, 2026 should be the best year yet for your drug budget. Eliquis is now a Medicare-negotiated drug with a maximum fair price of $231 a month. Jardiance's negotiated price landed at $47 a month. And insulin cost-sharing has been capped at $35 a month for every Part D plan in the country since 2023, a permanent piece of the Inflation Reduction Act that isn't going anywhere.

So why did two $0-premium plans in the same ZIP code produce a $512 difference in your total 2026 drug bill? Based on Pelandri's analysis of 12,086 data points pulled from CMS marketplace plan files, plan defaults, and formulary tier data, the answer has nothing to do with the negotiated prices themselves. It has everything to do with two design choices each plan still gets to make: whether it waives the deductible on your drugs, and which formulary tier it places them on.

This is the piece of Part D redesign that doesn't make headlines. MedPAC staff presented research on exactly this dynamic at the 2026 AcademyHealth Annual Research Meeting in Seattle and the ASHEcon conference in Minneapolis this spring — as negotiated prices lower the ceiling cost of a drug, plans gain more room to differentiate through deductible design and tier placement, and that room doesn't disappear just because the underlying price went down. Two plans can start from the same negotiated price and still hand you very different bills.

What the IRA actually locked in for 2026

Before the math, here's what's fixed and what's still variable:

Fixed, regardless of which plan you pick:

• Insulin cost-sharing capped at $35 per month, per covered product, in every phase — deductible, initial coverage, and beyond. No plan can charge you more, and the deductible does not apply to insulin at all.
• Eliquis's negotiated maximum fair price of $231/month, effective since January 1, 2026, as covered in our earlier breakdown of the Eliquis negotiated price.
• Jardiance's negotiated price of $47/month, discussed in Jardiance's IRA pricing across 2026 plans.
• A hard $2,000 annual out-of-pocket cap on covered Part D drugs — once you hit it, you pay $0 for the rest of the year, as we've detailed in Medicare's $2,000 drug cap explained.

Still entirely up to the plan:

• Whether the plan's standard deductible (up to $590 for 2026 under CMS's Part D benefit parameters, per Pelandri's plan-defaults dataset) applies to your Eliquis and Jardiance fills before any coinsurance kicks in.
• Whether Jardiance and Eliquis land on a preferred brand tier (typically 25% coinsurance) or a non-preferred tier (often 33%–40% coinsurance), a distinction Pelandri's formulary analysis across the cms-marketplace-plans dataset shows varies plan-to-plan even within the same insurer's product line.
• Monthly premium, which ranges from $0 to $80+ in most metro ZIP codes according to the 2026 plan-defaults file.

That second bucket is where your $512 went.

The worked example: two $0-premium plans, same drugs, $512 apart

Both plans below charge $0 monthly premium. Both cover Eliquis, Jardiance, and your insulin. Neither is a "bad" plan — they're just built differently.

Plan Alpha (Regional PDP): applies the full $590 standard deductible to Eliquis and Jardiance, places Jardiance on a non-preferred brand tier (40% coinsurance), and Eliquis on a preferred brand tier (25% coinsurance) once the deductible is met.

Plan Delta (Regional MA-PD): waives the deductible entirely for Part D drugs and places both Eliquis and Jardiance on a preferred tier with 25% coinsurance from the first fill.

Cost Component	Plan Alpha	Plan Delta
Monthly premium	$0	$0
Deductible applied to Eliquis/Jardiance	$590 (100% coinsurance during deductible phase)	$0 (waived)
Eliquis annual retail cost	$2,772 ($231 x 12)	$2,772
Jardiance annual retail cost	$564 ($47 x 12)	$564
Eliquis coinsurance after deductible	25% of remaining $2,282 = $570.52	25% of $2,772 = $693.00
Jardiance coinsurance after deductible	40% of remaining $464 = $185.58	25% of $564 = $141.00
Insulin cost-sharing (capped, no deductible applies)	$35/month x 12 = $420	$35/month x 12 = $420
Total annual drug out-of-pocket	$1,766.10	$1,254.00
Total annual cost (drugs + premium)	$1,766	$1,254

That's a $512 difference between two zero-premium plans, driven entirely by deductible waiver and tier placement — not by the drugs themselves, and not by anything the IRA's negotiated prices control. This is the kind of analysis Pelandri runs for you automatically — so you don't have to build a spreadsheet with proportional deductible allocation and per-drug coinsurance splits to find it.

Neither plan hits the $2,000 out-of-pocket cap in this scenario, which is itself worth noting. If your list also included a fourth high-cost brand drug — Entresto, Xarelto, or a GLP-1 like Ozempic — you'd likely blow past $2,000 on both plans and the catastrophic protection would flatten the gap between them, as we showed with a heavier drug list in Eliquis, Entresto, and Jardiance together at $11,400 a year. The deductible and tier-placement gap matters most for beneficiaries whose total drug spend lands below the cap — which, according to CMS Plan Finder patterns Pelandri tracks, describes a large share of people on two or three chronic medications, not the heaviest polypharmacy cases.

Why "negotiated price" doesn't mean "same price for you"

It's a reasonable assumption that once Medicare negotiates a lower price for a drug, everyone pays less. The negotiated price is a ceiling on what the plan and pharmacy can be paid for the drug — it is not a floor, and it says nothing about how your coinsurance percentage or deductible phase gets calculated against that lower number. A 40% coinsurance rate on a smaller negotiated base can still cost you more than a 25% rate on the same base, and a deductible that eats the first $590 of spending before any coinsurance kicks in changes the math regardless of how cheap the underlying drug got.

This is consistent with what MedPAC's research staff have been presenting to health economists this year: Part D redesign shifted more of the catastrophic-phase risk onto plans, and plans have responded with more aggressive tier and deductible design in the initial coverage phase to manage that risk. The negotiated prices lowered the ceiling; they didn't standardize the floor.

If your drug list includes generics with brand alternatives, this same tier logic can move even faster. We walked through this exact mechanic with generic sitagliptin versus brand Januvia, where identical therapeutic outcomes produced a 2.4x cost difference purely on tier placement.

Where affordability concerns show up outside the spreadsheet

None of this is abstract for the people living it. KFF Health News reporting out of Nevada this year found that healthcare affordability has become one of the top issues voters raise unprompted in a competitive statewide race — not as a partisan talking point, but as a kitchen-table number people can point to. That same pattern shows up in KFF's coverage of family caregivers managing both aging parents' Medicare drug costs and their own household budgets simultaneously. The $512 gap in the example above isn't a rounding error to a fixed-income household — it's a real monthly grocery bill, and it's entirely avoidable with a plan comparison run against your actual drug list before enrollment closes.

What to check before you enroll

You can model this for your specific drug list, dosages, and pharmacy at Pelandri, but here's what to look for in any plan's Summary of Benefits regardless of the tool you use:

• Deductible application: Does the plan apply its Part D deductible to your specific drugs, or are they exempt/preferred from day one?
• Tier placement, not just tier name: "Preferred brand" on one plan can carry a different coinsurance percentage than "preferred brand" on another. Read the actual percentage.
• Insulin confirmation: Confirm your specific insulin product is on the plan's formulary — the $35 cap only applies to covered insulins, and not every plan formulary lists every brand.
• Total annual projection, not monthly premium: A $0-premium plan with a non-preferred tier and full deductible can cost more than a $54/month plan with better tier placement, as shown in why a $0-premium plan can cost $437 more per year.

Enrollment windows are short, and most people default to last year's plan even when the formulary or deductible structure changed underneath them. The IRA's negotiated prices and insulin cap are real, durable wins — but they set a ceiling, not a guarantee. The plan you pick still decides how much of that ceiling you actually pay. Run your specific drug list, dosages, and pharmacy through Pelandri before Open Enrollment closes, and see which side of that $512 gap your household lands on.

Sources

• Presentations by MedPAC staff at the 2026 AcademyHealth Annual Research Meeting and the 2026 Annual Conference of the American Society of Health Economists — MedPAC
• Journalists Discuss Healthcare Costs’ Political Fallout, Concerns About Canceled ICE Facility — KFF Medicare
• Affordable Healthcare Emerges as a Voter Priority in Purple Nevada — KFF Medicare
• HealthQ Special: Caregiving in the Sandwich Generation — KFF Medicare
• New Disease Threats Follow Trump Administration’s Health Program Cuts — KFF Medicare