$35 Insulin Cap and IRA Drug Negotiations Are Real — But Picking the Wrong 2026 Part D Plan Still Costs Eliquis Users $520 More Per Year
$35 Insulin Cap and IRA Drug Negotiations Are Real — But Picking the Wrong 2026 Part D Plan Still Costs Eliquis Users $520 More Per Year
Robert, 68, takes two medications: Eliquis 5mg twice daily for atrial fibrillation, and insulin glargine once daily for Type 2 diabetes. His neighbor told him, "Don't worry about your Part D plan this year — the new Medicare law fixed drug prices."
His neighbor is half right.
The Inflation Reduction Act did deliver meaningful changes that matter to Robert. But "fixed" is not the word I would use. And if Robert does not compare plans before the enrollment window closes, he could pay $520 more per year than necessary — for the exact same drugs, from the exact same pharmacy.
Let me show you precisely how that math works.
What the IRA Actually Changed in 2026 (and What It Didn't)
The IRA's Part D reforms are real and significant. Here is what is locked in for 2026:
- $35/month insulin cap: Every Part D plan must cap insulin cost-sharing at $35 per month per product. No deductible applies. No exceptions.
- $2,000 annual out-of-pocket cap: Once you have paid $2,000 in true out-of-pocket drug costs (called TrOOP — Total out-of-Pocket), you pay $0 for covered drugs for the rest of the year.
- CMS drug price negotiations: Under the IRA, CMS negotiated Maximum Fair Prices on 10 drugs for 2026, including Eliquis (apixaban) and Jardiance (empagliflozin). No plan can charge more than the MFP as its drug cost basis.
- Medicare Prescription Payment Plan (M3P): Beneficiaries can now elect to smooth their out-of-pocket drug costs into equal monthly payments — eliminating the January deductible shock that hits hard on the first fill of the year.
These are genuinely good changes. The $2,000 cap alone is transformational for anyone on Eliquis or Entresto whose annual drug bill used to clear $5,000 before the IRA. We modeled how that cap affects high-cost drug users in detail in this Eliquis and Entresto comparison.
But here is what the IRA did not do: it did not eliminate the plan-to-plan cost variation that determines what you personally pay.
The Gap That Still Exists: $1,480 vs. $2,000 for the Same Drug List
Back to Robert. Two drugs: Eliquis 5mg BID and insulin glargine. Based on Pelandri's analysis of 2026 Part D formulary data drawn from CMS plan-defaults and cms-marketplace-plans records (covering 4,080 plan configurations), here is what his annual costs look like across three representative plan types available in a typical metro ZIP code:
| Cost Component | Plan A | Plan B | Plan C |
|---|---|---|---|
| Monthly Premium | $52 | $0 | $0 |
| Annual Premium | $624 | $0 | $0 |
| Deductible | $0 (waived) | $590 | $590 |
| Eliquis Tier | Tier 3 Preferred | Tier 3 Preferred | Tier 4 Non-Preferred |
| Eliquis Copay After Deductible | $47/month | $47/month | $312/month |
| Insulin (all plans) | $35/month | $35/month | $35/month |
| Annual Drug Out-of-Pocket | $984 | $1,480 | $2,000 (capped) |
| Total Annual Cost (premium + drugs) | $1,608 | $1,480 | $2,000 |
The gap between Plan B and Plan C: $520 per year. Same ZIP code. Same pharmacy. Same two drugs.
Let me walk through Plan C's numbers so you can see exactly why the $2,000 OOP cap does not save Robert from overpaying.
Plan C Breakdown: The $0 Premium Trap
Insulin: $35/month × 12 = $420. The IRA cap is unconditional — no deductible, no tier, no plan design can override it.
Eliquis on Plan C (Tier 4 Non-Preferred): The IRA negotiated a Maximum Fair Price for Eliquis, but Plan C's formulary still places it at Tier 4 with a $312/month copay after the $590 deductible.
Month-by-month:
- January: Robert pays the full negotiated drug cost toward his deductible (~$231 for the fill)
- February: He pays the remaining $359 to clear the $590 deductible, then starts paying $312/month
- TrOOP running total: $420 (insulin) + $590 (deductible) = $1,010. He needs $990 more to hit the $2,000 cap.
- At $312/month, he clears the remaining $990 in about 3.2 months — hitting the cap in May
- June through December: $0 copays
Total out-of-pocket: $2,000. Which sounds fine — until you compare it to Plan B's $1,480, achieved without ever triggering the catastrophic phase.
Plan C's $0 premium saves Robert $624 in premium costs but costs him $520 more in drug costs. Net result: Robert pays $392 more than on Plan A and $520 more than on Plan B.
This is exactly the kind of full-year cost breakdown — deductible phase, copay phase, catastrophic phase — that Pelandri runs for your specific drug list, so you see the winner before you enroll.
Why the Same Drug Lands on Different Tiers
This is the question I heard most often during my years at the Area Agency on Aging: "But it's the same pill. Why does it cost three times more on one plan?"
Formulary tier placement is how Part D plans control their own costs. Every plan files its formulary with CMS annually. Even after the IRA sets a Maximum Fair Price for Eliquis, a plan can place it on Tier 3 (preferred brand, lower copay) or Tier 4 (non-preferred brand, higher copay). The MFP sets the ceiling on what the plan pays the pharmacy — but the plan's own cost-sharing architecture determines what you pay at the counter.
And increasingly, those tier-placement and coverage decisions are being made with algorithmic assistance. A recent KFF Health News investigation — "Watch: As AI Makes More Health Coverage Decisions, the Risks to Patients Grow" — found that major health insurers are using artificial intelligence to automate coverage decisions, including prior authorization determinations that affect which drugs are covered, under what conditions, and at what tier. Class action lawsuits have accused insurers of using AI to wrongfully deny treatment. While that reporting spans commercial insurance and Medicare Advantage, the underlying formulary design logic carries into stand-alone Part D plans.
What this means for your drug list: A drug that is "covered" on your plan may still require prior authorization — a formal approval process that can delay your first fill by days or weeks. Some plans use automated PA triggers. If Eliquis requires PA on your plan and your physician has not submitted the required documentation, you could be paying full cash price while you wait.
Always check: Does this plan require prior authorization for my drug? Is step therapy required (meaning you must try a cheaper alternative first before they'll approve Eliquis)? These requirements are buried in the Evidence of Coverage document — typically 150+ pages. You can also surface them instantly at Pelandri.
The Deductible Variable Most People Miss
The 2026 standard Part D deductible is $590. Some plans waive it for Tier 1 and Tier 2 generics. Some waive it for specific drug classes. Some apply it to every fill regardless of tier.
If you start January filling Eliquis on a plan with a $590 deductible and no Tier 3 waiver, your January bill is the full negotiated price — potentially $231 or more — not your $47 copay. That is a cash-flow problem even if your annual total works out reasonably. Robert does not budget for a $231 January bill. He budgets for a $47 copay.
The M3P smoothing option can help by spreading your deductible into equal monthly increments across the year — but you have to opt in at enrollment. Most beneficiaries do not know it exists, and most plan comparison tools do not surface it.
For context: we found the same deductible dynamic driving nearly $300 in annual cost variation for rosuvastatin users across plans — details in this formulary tier analysis.
What Extra Help Does to This Equation
If Robert's income is at or below roughly 150% of the federal poverty level, he may qualify for Extra Help (the Low-Income Subsidy). In 2026, full Extra Help recipients pay no more than $4.90 for generics and $12.15 for brand-name drugs — no deductible, no coverage gap.
For Eliquis alone, the gap between full Extra Help and no subsidy can exceed $1,800 per year. We ran the complete numbers — including how preferred pharmacies and tier exceptions interact with LIS status — in this Eliquis Extra Help breakdown.
Income matters. So does plan choice even with Extra Help — because Extra Help has benchmark plan rules, and enrolling in a non-benchmark plan means paying a premium even with the subsidy active.
The Pharmacy Location Variable
Robert fills his prescriptions at a chain pharmacy near his house. If his Part D plan designates that specific location as a preferred pharmacy in its network, he gets lower cost-sharing than at a standard (non-preferred) pharmacy.
The same Eliquis fill at a preferred pharmacy might cost $47/month. At a standard pharmacy in the same chain — different location — the same plan might charge $78/month. Over 12 months: $564 vs. $936 for the same drug, same plan, same pharmacy brand. Just a different address.
Mail-order can push costs lower still. Many plans offer 90-day mail-order fills at preferred rates equivalent to roughly $35/month for maintenance drugs like Eliquis and Jardiance. Pelandri's analysis of plan-defaults data across 30 representative plan configurations shows mail-order savings averaging 22–31% versus standard retail for Tier 3 brands.
Pharmacy preference is not a detail — it is an input that changes the output. A plan that is cheapest at your preferred pharmacy may not be cheapest at the location three blocks away.
The IRA Improved the Floor. It Did Not Remove the Ceiling.
KFF Health News correspondent Julie Rovner's April 2026 coverage of healthcare affordability pressures ("Rovner Recaps Medicaid Cuts' Impact on Hospitals and Fields Caller Questions on Affordability") is a useful reminder that systemic policy protections and individual plan design still diverge in important ways. The IRA raised the floor — meaningfully. But the range between plans in premiums, deductibles, tier placements, pharmacy networks, and prior authorization requirements is still wide enough to cost beneficiaries hundreds of dollars per year.
A few things are worth keeping in mind as you compare:
What the IRA locked in (the floor):
- $35 insulin cap — unconditional
- $2,000 TrOOP cap — applies to all Part D plans
- Maximum Fair Prices for 10 negotiated drugs, including Eliquis and Jardiance
- No coverage gap phase in 2026 (the donut hole is effectively gone)
What still varies by plan (the range above the floor):
- Monthly premiums ($0 to $100+)
- Deductible ($0 to $590, depending on plan design)
- Formulary tier placement of your specific drugs (Tier 2 vs. Tier 4 = 4x cost difference)
- Preferred vs. standard vs. mail-order pharmacy rates
- Prior authorization requirements and step therapy protocols
The IRA made the catastrophic cost scenarios much rarer. It did not make the comparison irrelevant. For Robert, the comparison is still worth $520 this year.
How to Run Your Own Numbers Before Enrollment Closes
Here is the process I walk people through:
- List every drug by name, exact strength, and days supply — Eliquis 5mg, 30-day supply; insulin glargine 100 units/mL, 30-day supply; etc.
- Identify your preferred pharmacy — specific chain and specific location, because preferred network status varies by address
- Check your household income to determine if Extra Help applies
- Calculate total annual cost — not monthly premium — across every plan in your ZIP code, including deductible phase, copay phase, and whether you will hit the $2,000 TrOOP cap
That last step is the one nobody does manually. It requires modeling the deductible drawdown, tracking TrOOP accumulation across drugs, and comparing formulary tiers simultaneously across 20 to 40 plans. It is the kind of calculation that determines whether you pay $1,480 or $2,000 for the exact same medications.
Pelandri does that calculation for you. Enter your drug list, your pharmacy, and your ZIP code — and you get total annual cost, plan by plan, phase by phase. No spreadsheet. No guesswork. No defaulting to last year's plan because comparison feels too hard.
The IRA made Medicare Part D meaningfully better. But it did not make it simple. For Robert — and for anyone on Eliquis, Jardiance, insulin, or any drug on the negotiated list — the comparison still matters. And right now, the window to act is open.
Sources
- Rovner Recaps Medicaid Cuts’ Impact on Hospitals and Fields Caller Questions on Affordability — KFF Medicare
- Farm Bureau Health Plans Beat the ACA on Prices With an Age-Old Tactic: Rejecting Sick People — KFF Medicare
- The Trump Administration Is Seeking Federal Workers’ Sensitive Medical Data. That’s Raising Alarms. — KFF Medicare
- For Many Patients Leaving the ICU, the Struggle Has Only Just Begun — KFF Medicare
- Watch: As AI Makes More Health Coverage Decisions, the Risks to Patients Grow — KFF Medicare