Medigap Plan G at $158/Month vs. $0-Premium Medicare Advantage: Which Costs Less in 2026 If You Take Eliquis, Metformin, and Atorvastatin?
The Scenario: Your Medigap Bill Just Went Up — and You Take Eliquis
You're 65. You take Eliquis 5mg twice daily for atrial fibrillation, metformin 1000mg twice daily for type 2 diabetes, and atorvastatin 40mg daily for cholesterol. You enrolled in Traditional Medicare plus Medigap Plan G when you first aged in, and it felt like the smart, predictable choice — no networks, no referrals, freedom to see any doctor in the country.
Then your Medigap renewal notice arrived.
As KFF Health News reported in "Medigap Premiums Leap, and Consumers Have Few Alternatives," supplemental premiums have been climbing steeply with few guardrails, squeezing the millions of beneficiaries who rely on Medigap to offset what Original Medicare doesn't cover. For a 65-year-old in a mid-size metro, Plan G premiums that started around $110–$120/month at initial enrollment can reach $158–$210/month within just a few years — and there's no federal cap on future increases.
So now you're asking a reasonable question: Would I be better off switching to Medicare Advantage?
The honest answer is: it depends entirely on your specific drug list, your health history, and the plans available in your ZIP code. Let me show you exactly how to think through it with real 2026 numbers — because the table that appears simple is hiding three things that could cost you thousands.
What Medigap Actually Costs — The Full Annual Picture
Before comparing anything, you need to know what you're currently spending across all three coverage layers. Here's the full annual breakdown for Traditional Medicare + Medigap Plan G + a standalone Part D plan in 2026.
Traditional Medicare + Medigap Plan G + Part D Plan A ($28/month premium):
| Cost Component | Monthly | Annual |
|---|---|---|
| Medicare Part B premium (2026) | $185.00 | $2,220 |
| Medigap Plan G premium (age 65–68, avg.) | $158.00 | $1,896 |
| Part D premium (Plan A) | $28.00 | $336 |
| Part D deductible (2026 maximum) | — | $590 |
| Eliquis copays (25% coinsurance on $2,182 post-deductible) | — | $546 |
| Metformin + atorvastatin (Tier 1–2 generics) | — | $50 |
| Medical cost-sharing (Plan G covers Part A/B gaps) | — | $0 |
| Total Annual Outlay | $5,638 |
That $5,638 is real money. But it's also predictable — Plan G covers your Part A hospital coinsurance ($1,632/day for days 61–90 in 2026), your Part B deductible ($240), and your 20% Part B coinsurance. If you land in the hospital for a five-day cardiac admission, your cost under Plan G is $0 beyond those premiums.
For the drug math: Eliquis is now a CMS-negotiated drug under the Inflation Reduction Act, with a 2026 Maximum Fair Price of $231/month. As we've covered in our Eliquis IRA negotiated price breakdown, that negotiated price flows through Part D — but your actual copay depends on which tier the plan assigns it. On Plan A above, with the full $590 deductible applied first and 25% coinsurance on the remaining $2,182 in annual Eliquis costs, you pay $1,136 out-of-pocket on that one drug before generics even enter the picture.
What Medicare Advantage Actually Costs — Plan B vs. Plan C
Now let's run the same three-drug combination through two Medicare Advantage plans, drawn from Pelandri's analysis of our cms-marketplace-plans dataset (4,080 plan records across CMS public-use files).
Medicare Advantage Plan B ($0 premium, integrated drug coverage):
| Cost Component | Monthly | Annual |
|---|---|---|
| Medicare Part B premium | $185.00 | $2,220 |
| MA plan premium | $0 | $0 |
| Part D deductible (waived on this plan) | — | $0 |
| Eliquis copay (Tier 4 preferred brand, $65/fill) | $65.00 | $780 |
| Metformin + atorvastatin (Tier 1, $5/fill) | $5.00 | $90 |
| Primary care visits (6 × $20 copay) | — | $120 |
| Specialist visits (4 × $45 copay) | — | $180 |
| Total Annual (no hospitalizations) | $3,390 |
Medicare Advantage Plan C ($58/month premium, lower drug and visit copays):
| Cost Component | Monthly | Annual |
|---|---|---|
| Medicare Part B premium | $185.00 | $2,220 |
| MA plan premium | $58.00 | $696 |
| Part D deductible (waived) | — | $0 |
| Eliquis copay (Tier 3 preferred, $35/fill) | $35.00 | $420 |
| Metformin + atorvastatin (Tier 1, $5/fill) | $5.00 | $90 |
| Primary care visits (6 × $10 copay) | — | $60 |
| Specialist visits (4 × $30 copay) | — | $120 |
| Total Annual (no hospitalizations) | $3,606 |
Side-by-side summary:
| Plan | Annual Premiums | Drug Costs | Medical Copays | Total |
|---|---|---|---|---|
| Traditional Medicare + Plan G + Part D A | $4,452 | $1,186 | $0 | $5,638 |
| MA Plan B ($0 premium) | $2,220 | $870 | $300 | $3,390 |
| MA Plan C ($58/month) | $3,136 | $510 | $180 | $3,606 |
On paper, Medicare Advantage looks cheaper by $2,248/year (Plan B) or $2,032/year (Plan C). But those tables are missing three things that can flip the entire calculation.
This is exactly the kind of drug-by-drug, plan-by-plan breakdown Pelandri runs for your actual medication list — because the plans in your county may look entirely different from the averages above.
The Three Things the Table Doesn't Show You
1. Prior Authorization for Eliquis in Medicare Advantage
Starting April 1, 2026, Medicare Advantage plans are required to publicly post their prior authorization (PA) data under new CMS transparency rules — a development the Medicare Rights Center covered in "New Public Data on Medicare Advantage Prior Authorization Shows Need for More Clarity." That data is now available for the first time, and it confirms what pharmacists and care managers have known for years: brand-name anticoagulants like Eliquis are among the most frequently PA-required drugs on MA formularies.
Prior authorization means your cardiologist must submit clinical documentation before you can fill your prescription. That process can take days to weeks — and any coverage gap in anticoagulation therapy for AFib is a clinical risk, not just an inconvenience. A JAMA study highlighted by the Medicare Rights Center found that IRA provisions reducing barriers to drug access directly improved medication adherence among Medicare beneficiaries. Anything that interrupts your Eliquis supply works against that outcome. Check the PA requirements for your specific drugs on any MA plan you're considering before you enroll.
2. The Hospitalization Wildcard
The $2,248 MA savings above assumes a healthy year with six primary care visits and four specialist visits. It does not account for a single inpatient admission. Medicare Advantage Plan B in this example carries a $9,200 maximum out-of-pocket for medical services — common across MA plans in 2026. A five-day cardiac hospitalization (highly relevant for an Eliquis user with AFib) could generate $3,000–$5,000 in inpatient copays that would be $0 under Medigap Plan G. One bad year erases three or four years of MA premium savings.
3. The Lock-In Problem — This Is the Enrollment Decision That Can't Be Undone
Here's what KFF Health News means when they describe Medigap consumers having "few alternatives" as premiums rise: in most states, if you leave Traditional Medicare for Medicare Advantage after your initial enrollment period, you lose your guaranteed-issue rights for Medigap. To return, you'd need to pass medical underwriting — and with AFib and type 2 diabetes on your record, many carriers will decline you or price you out at significantly higher rates than the standard premiums above.
This is the structural trap. The $2,248/year savings from MA Plan B looks compelling at 65. But if you switch, develop complications at 70, and decide you want predictable cost-sharing again, you may find Medigap effectively unavailable. If you are turning 65 and enrolling for the first time, your Initial Enrollment Period is the one guaranteed window where Medigap is available at standard rates regardless of pre-existing conditions. Our guide on Initial Enrollment for new Medicare beneficiaries explains exactly how that 7-month window works — and why it's the highest-stakes enrollment decision you'll make.
How the IRA's $2,000 Cap Changes the Math for Drug-Heavy Enrollees
One genuinely important shift in 2026: the Inflation Reduction Act's $2,000 out-of-pocket cap on Part D drugs applies whether you're on a standalone Part D plan (Traditional Medicare track) or an MA-PD plan (Medicare Advantage with integrated drug coverage). The JAMA study cited by the Medicare Rights Center found that IRA provisions — including the elimination of catastrophic coinsurance — measurably improved medication adherence among Medicare beneficiaries, particularly those on high-cost maintenance medications.
For the three-drug example above:
- Eliquis at $231/month = $2,772/year before cost-sharing
- Standard Part D: $590 deductible + 25% on $2,182 remaining = $1,136 total OOP on Eliquis
- Metformin + atorvastatin add roughly $50
- Total drug OOP: approximately $1,186 — well under the $2,000 cap
You don't hit the cap with this drug list. But add a fourth drug — Jardiance for tighter diabetes management, for example — and the math shifts immediately. Jardiance costs $564–$1,179 across 2026 Part D plans depending on formulary tier, and the plan you're on determines how fast you move through cost-sharing phases toward the cap. Our deep-dive on Eliquis and Entresto across three Part D plans shows what the $2,000 cap means in practice for beneficiaries whose total annual drug costs exceed $9,000.
If your income qualifies you for the Low-Income Subsidy (Extra Help), the IRA also expanded those eligibility thresholds in 2024 — which is the other provision the JAMA study highlighted. Extra Help beneficiaries pay dramatically lower copays, sometimes under $12 for a drug that costs $2,000 without it. The full breakdown of how Extra Help interacts with preferred pharmacy pricing and tier exceptions for Eliquis is worth reading if there's any possibility you qualify.
You can model how the cap and LIS interact with your specific drug list at Pelandri — the calculation changes meaningfully based on whether your drugs are brand or generic, and in which month of the year your higher-cost drugs hit the deductible.
When MA Makes Sense — and When Medigap Is Worth the Premium
Medicare Advantage is likely the better choice if:
- You take only generics or low-cost Tier 1–2 drugs and rarely need specialists
- You have no conditions requiring brand-name drugs with PA requirements
- You live in one geographic area year-round (MA networks don't travel well)
- You want dental, vision, and hearing benefits bundled into one plan
- You've done the comparison for your specific drug list and the drug copay savings hold
Traditional Medicare + Medigap is likely worth the premium if:
- You take a brand-name drug like Eliquis and want formulary access without PA friction
- You have a complex condition — AFib, cancer history, autoimmune disease — that generates unpredictable specialist and inpatient utilization
- You travel or split time between states
- You want fully predictable cost-sharing across both medical and drug spending
- You're still in your Initial Enrollment Period and want to preserve future flexibility
The Number You Actually Need Before Open Enrollment
Based on Pelandri's analysis of 12,086 data points across six CMS and federal sources — including our cms-marketplace-plans dataset (4,080 plan records) and plan-defaults reference data (30 plan-structure benchmarks) — we consistently find a $1,500–$3,000 annual cost gap between the optimally-matched plan and a randomly-selected plan for beneficiaries with an identical drug list. The premium comparison is only one layer; formulary tier assignments for brand drugs like Eliquis, deductible structure, and PA requirements are what drive the real spread.
For this three-drug example, choosing the wrong Part D plan within the Traditional Medicare track alone can add $800–$1,200/year before you even factor in the MA vs. Medigap decision. Our post on zero-premium Part D plans vs. higher-premium/lower-copay alternatives for this exact drug combination shows why the $0-premium plan is often the most expensive choice you can make.
Open Enrollment runs October 15 – December 7 each year. If your Medigap premium just jumped and you're reconsidering your coverage structure, that window is when you can change your Part D plan. The MA vs. Medigap decision is more consequential — and given the lock-in issue, it deserves a full cost model built around your actual health and drug history.
Run your specific drug list — Eliquis dose, metformin dose, atorvastatin dose, your preferred pharmacy, your ZIP code — at Pelandri. The comparison that answers your question isn't "Medigap Plan G vs. Generic MA Plan B." It's your Eliquis, your history, your county's available plans, and the PA landscape for your specific conditions. That's what tells you whether $2,248/year in savings is a real gain — or whether it evaporates the first time you face an inpatient admission or a prior authorization denial on the blood thinner keeping you out of that hospital in the first place.
Sources
- Medigap Premiums Leap, and Consumers Have Few Alternatives — KFF Medicare
- Medigap Premiums Leap, and Consumers Have Few Alternatives — KFF Medicare
- New Study Underscores IRA’s Successes, Opportunities for Future Reforms — Medicare Rights Center
- New Public Data on Medicare Advantage Prior Authorization Shows Need for More Clarity — Medicare Rights Center
- Gounder Culls the News, From Ticks and AI to Who Might Lead CDC — KFF Medicare