Is the $35 Insulin Cap at Risk in 2026? What It Means for Your Eliquis and Jardiance Part D Bill

You take Eliquis for atrial fibrillation, Jardiance for type 2 diabetes, and insulin glargine to keep your blood sugar steady. Three drugs, one 71-year-old Chicago retiree named Robert — and depending on which Part D plan he picks for 2026, his annual out-of-pocket bill lands anywhere between $1,356 and $2,112. Same drugs. Same pharmacy network area. A $756 difference just from plan selection.

That gap exists inside a system that's actually gotten a lot more generous to beneficiaries in the last few years. The Inflation Reduction Act (IRA) gave Medicare enrollees a hard $2,000 out-of-pocket cap on Part D drugs, a flat $35-a-month cap on insulin, and — for the first time ever — the authority for Medicare to negotiate prices directly with drug manufacturers. The Medicare Rights Center's recent piece, "What's at Stake in 2026: The Inflation Reduction Act," is a useful reminder that none of this existed before 2022. There was no OOP cap, no negotiated prices, and no insulin ceiling. If you were on Medicare in 2021, your drug costs could — and often did — climb indefinitely.

But "what's at stake" is the operative phrase. These protections are law today. Whether every piece of them stays fully funded, fully enforced, and fully intact through the rest of this decade is a separate question — and it's one you should factor into how you shop for a plan this Open Enrollment, not something to assume away.

What the IRA Actually Changed — And What's Still Being Fought Over

Three pieces matter for your prescription bill in 2026:

The $2,000 out-of-pocket cap. Once your true out-of-pocket spending (what Medicare calls TrOOP — true out-of-pocket costs) hits $2,000 in a calendar year, your Part D drug costs drop to $0 for the rest of the year. The old "donut hole" coverage gap is gone; Part D now runs through just three phases — deductible, initial coverage, and catastrophic (the $0 phase).

The $35 insulin cap. Every insulin product covered under Part D is capped at $35 per month per prescription, regardless of formulary tier, and it's exempt from the deductible. It counts toward your $2,000 cap, but you'll never pay more than $35 for it in a single month.

Drug price negotiation. Eliquis is one of the first ten drugs CMS negotiated directly with the manufacturer, bringing its negotiated price down substantially starting in 2026. Jardiance is in a later negotiation cohort with its own reduced price taking effect.

Here's the part that doesn't get enough attention: the Medicare Rights Center's piece flags that funding mechanisms behind these provisions — and the political appetite to preserve them — are contested year to year. Separately, KFF Health News reported in "Trump and Kennedy's Health Industry Deals Haven't Been Enforced and Are at Risk of Vanishing" that several high-profile drug pricing and industry agreements announced with fanfare haven't actually been enforced, and some are at risk of quietly disappearing. That's not a reason to panic about your 2026 costs — the $2,000 cap and $35 insulin cap are current law and reflected in every plan's 2026 benefit design. It is a reason not to assume this year's numbers will look identical next year, and not to put your plan selection on autopilot.

The Math: Same Three Drugs, Three Plans, $756 Difference

Let's run Robert's numbers using Chicago-area (ZIP 60614) 2026 Part D benefit design parameters. Under the IRA redesign, the standard deductible is applied first, then 25% coinsurance in the initial coverage phase, then $0 once TrOOP hits $2,000.

Robert's negotiated-price drug costs (what the plan pays the pharmacy, before his cost-sharing):

• Eliquis 5mg, twice daily: ~$231/month negotiated price = $2,772/year
• Jardiance 25mg, once daily: ~$175/month negotiated price = $2,100/year
• Insulin glargine: capped at $35/month for Robert regardless of ingredient cost

Plan A — $0-premium standard design. Deductible ($590) applies to Eliquis and Jardiance first. After that, Robert pays 25% coinsurance on the remaining $4,282 in combined ingredient cost, plus his flat $35/month insulin copay. He hits the $2,000 TrOOP cap around month nine — after that, every drug on his list is $0 for the rest of the year. Total annual drug spend: exactly $2,000. Premium: $0. Total: $2,000.

Plan B — enhanced flat-copay design, $54/month premium. This plan waives the deductible but charges flat copays: $47/month for Eliquis, $40/month for Jardiance, $35/month for insulin. That's $122/month, or $1,464/year — and Robert never accumulates enough TrOOP to hit the $2,000 cap, so he pays the full $1,464 in copays. Add the $648 annual premium. Total: $2,112.

Plan C — preferred mail-order pharmacy, $33/month premium. Using 90-day mail order through the plan's preferred pharmacy, Eliquis drops to $25/month, Jardiance to $20/month, insulin stays at $35/month. That's $80/month, or $960/year, plus $396 in annual premium. Total: $1,356.

Plan	Monthly Premium	Annual Premium	Drug Out-of-Pocket	Total Annual Cost
Plan A — $0-Premium Standard	$0	$0	$2,000 (hits cap ~month 9)	$2,000
Plan B — Enhanced Flat-Copay	$54	$648	$1,464 (never hits cap)	$2,112
Plan C — Preferred Mail-Order	$33	$396	$960 (never hits cap)	$1,356

Notice the counterintuitive result: the $0-premium plan isn't the cheapest, and it isn't the most expensive either — it lands in the middle because Robert's coinsurance structure pushes him all the way to the $2,000 ceiling, while the flat-copay plan (Plan B) actually keeps his raw drug spending lower ($1,464) but the premium tips the total past Plan A's cost. This is the kind of interaction — deductible design, coinsurance versus flat copay, mail-order discounts, and where the $2,000 cap sits relative to your specific drug costs — that a premium number alone will never tell you. It's the same dynamic we broke down in Medicare's $2,000 Drug Cap Explained: the cap is a ceiling on drug costs, not on your total Medicare spending, and your premium sits entirely outside it.

This is the kind of analysis Pelandri runs for you — so you don't have to build the spreadsheet yourself for every plan in your ZIP code.

The MA Overpayment Wildcard: Why "Set and Forget" Is a Bad Strategy for 2026

A second Medicare Rights Center piece this month, "Evidence of MA Overpayment Continues to Mount," cites a Committee for a Responsible Federal Budget analysis projecting up to $1 trillion in Medicare Advantage overpayments over the next decade. That's not a Part D headline directly, but it matters for the same reason the "at stake" framing matters: it's evidence of sustained budget pressure inside the Medicare program. Historically, when CMS or Congress looks for savings, plan bid structures, subsidy levels, and benefit parameters are exactly where adjustments show up — including the annual recalculation of the deductible, the OOP cap threshold, and low-income subsidy (Extra Help/LIS) parameters that determine how much beneficiaries pay.

None of that changes Robert's 2026 numbers. But it's a strong argument against assuming your current plan — or last year's "winner" — is still the right call this year. Pelandri's underlying plan-defaults dataset, which tracks CMS's annually published Part D benefit parameters (deductible, initial coverage limit, catastrophic threshold), shows these figures move every single year, sometimes by design and sometimes in response to exactly the kind of budget pressure the CRFB report is flagging. If you took the standard deductible ($590 in 2025) and projected it forward using the same trendline our bls-medical-cpi dataset shows for prescription drug and medical care inflation over the past 36 months, you'd expect continued upward drift — meaning the "free ride" after your deductible in January gets a little more expensive to reach every year, even before you factor in formulary or tier changes on your specific plan.

What Extra Help Changes About This Math

If Robert qualified for Extra Help (the Low-Income Subsidy), none of the numbers above would apply — LIS enrollees pay fixed, much lower copays regardless of which plan they're on, and the deductible is waived entirely. We've walked through that comparison in detail for Eliquis specifically in Eliquis Costs $144/Year With Extra Help vs $2,000 Without It, and it's worth checking your own income and asset numbers against the 2026 LIS thresholds before you assume you don't qualify — a lot of beneficiaries just above the old thresholds now qualify under expanded IRA eligibility rules.

How to Check Your Own Numbers Before Enrollment Closes

Robert's $756 spread came from exactly three variables: coinsurance versus flat copay design, mail-order versus retail pharmacy pricing, and how fast his TrOOP accumulates toward $2,000. Change the drug list — swap Jardiance for Farxiga, or add a fourth maintenance drug — and the ranking of Plan A, B, and C can flip entirely. That's the core problem with Medicare Plan Finder's default premium sort: it optimizes for the wrong number.

You can model this for your specific drug list, dosages, and pharmacy preference at Pelandri, which runs the deductible-through-catastrophic math across every plan available in your ZIP code — the same calculation we just walked through for Robert, but for your actual prescriptions.

Bottom Line

The $2,000 cap, the $35 insulin cap, and negotiated prices on drugs like Eliquis are real, current law shaping your 2026 Part D bill — not a "someday" policy promise. But as the Medicare Rights Center and KFF reporting both make clear this year, the political and budgetary environment around these provisions is not static, and neither are the plan-level details that determine how much of that protection you actually capture. A $0 premium doesn't guarantee the lowest bill. A flat-copay plan doesn't guarantee you'll hit the cap. The only way to know which plan is cheapest for your exact drugs is to run the math before Open Enrollment closes — not after you've already defaulted into next year's plan.

Sources

• What’s at Stake in 2026: The Inflation Reduction Act — Medicare Rights Center
• Evidence of MA Overpayment Continues to Mount — Medicare Rights Center
• With Midterms Looming, Journalists Consider Measles, Food Recalls, and Obamacare — KFF Medicare
• Trump and Kennedy’s Health Industry Deals Haven’t Been Enforced and Are at Risk of Vanishing — KFF Medicare
• High Fertility Costs Push Americans Abroad for IVF Treatment — KFF Medicare