Xarelto and Farxiga Cost $350/Year With Extra Help vs $2,540 Without It: How LIS, Preferred Pharmacies, and Tier Exceptions Cut Your 2026 Part D Bill
You take Xarelto and Farxiga. Here's what that actually costs.
If your medication list includes Xarelto 20mg (a brand-name blood thinner) and Farxiga 10mg (a brand-name SGLT2 diabetes drug), plus a generic like lisinopril 20mg for blood pressure, your total annual Part D bill can land anywhere between $350 and $7,500 or more — for the exact same three prescriptions. The difference isn't your health. It's whether you're enrolled in Extra Help, whether your pharmacy is "preferred" under your plan's network, whether you're filling 30-day or 90-day supplies, and whether Farxiga even sits on your plan's formulary without a fight.
This is the kind of variation KFF Health News' journalists have been fielding questions about in recent national and local media appearances discussing healthcare affordability as a top-of-mind issue for households this year. It's also exactly why MedPAC staff spent time this summer presenting research at the AcademyHealth Annual Research Meeting and the ASHEcon conference on how the post-redesign Part D benefit — with its $2,000 out-of-pocket cap — actually plays out for real beneficiaries. The benefit design changed. The confusion didn't go away.
Let's walk through the math for your specific drugs, because the national conversation about affordability means nothing until you know what YOUR list costs on YOUR plan.
The three levers that decide your bill
Before the numbers, three pieces of Medicare vocabulary you need translated:
- Extra Help (also called LIS, Low-Income Subsidy): A federal program that caps what you pay per prescription — often $4.90 for a generic and $12.15 for a brand-name drug in 2026 — and eliminates your deductible entirely if you qualify.
- TrOOP (True Out-of-Pocket costs): The running total of what you and certain others (not manufacturer coupons) have paid toward your $2,000 annual cap. Once TrOOP hits $2,000, you owe $0 for covered drugs for the rest of the year.
- Tier exception: A formal request asking your plan to cover a higher-tier or non-formulary drug at a lower cost-sharing tier, usually requiring your doctor to document medical necessity.
Here's the part most people miss: since the 2025 redesign, the $2,000 out-of-pocket cap is the same dollar figure on every Part D plan in the country. So for someone on expensive brand drugs like Xarelto and Farxiga, the coinsurance percentage barely matters — you're going to reach that $2,000 ceiling regardless of which standard plan you pick. What actually separates a good plan from a bad one for your list is: your monthly premium, how fast you reach the cap (cash flow), and — critically — whether the drug is covered at all without a prior authorization denial standing between you and the formulary.
Scenario 1: Full Extra Help
If you qualify for full Extra Help (LIS Level 1), your deductible disappears and your copays are fixed regardless of retail price:
- Lisinopril (generic, tier 1): $4.90/month
- Xarelto (brand, tier 3): $12.15/month
- Farxiga (brand, tier 3): $12.15/month
Monthly total: $29.20. Annual total: $350.40. No premium, no deductible, no coinsurance math required. Once your TrOOP crosses the catastrophic threshold, your copays for these drugs typically drop even further or hit $0, depending on your specific LIS eligibility category.
This is the same dynamic we walked through for a different drug combination in Eliquis From $112 to $11/Month and again in Gabapentin and Letrozole — Extra Help isn't a marginal discount. It's the single biggest lever in the entire Part D system, and it applies at the pharmacy counter regardless of which plan you're enrolled in.
Scenario 2: Standard plan, drugs on formulary, no complications
Say you don't qualify for Extra Help. You're on a standard Part D plan with a $45/month premium, a $615 deductible (the 2026 standard, per CMS Part D design parameters), and 25% coinsurance during the initial coverage phase.
Here's the walkthrough:
- You pay the full $615 deductible out of pocket before coverage kicks in on brand drugs. That $615 counts toward your $2,000 TrOOP.
- You need $1,385 more in TrOOP to hit the $2,000 cap. At 25% coinsurance, that corresponds to $5,540 in underlying drug costs — easily reached, since Xarelto alone runs roughly $550/month retail and Farxiga roughly $580/month retail (combined annual retail cost north of $13,500).
- You'll hit the $2,000 TrOOP cap around month five or six of the year.
- After that, you owe $0 for covered drugs for the rest of the year — including your lisinopril refills.
Total annual cost: $540 (premium) + $2,000 (out-of-pocket cap) = $2,540.
That's a real number, and it's the ceiling for anyone whose drugs are fully covered on formulary. Compare that to the $350 Extra Help scenario, and you can see why applying for LIS — even at partial-subsidy income levels — is worth checking before you assume you don't qualify.
Scenario 3: The tier exception trap
Here's where things get expensive fast. Not every plan places Farxiga on its formulary at the same tier — some place it as a preferred brand (tier 3), others as non-preferred (tier 4), and a few may exclude it entirely in favor of a different SGLT2 inhibitor, requiring step therapy or prior authorization before they'll cover it.
If Farxiga isn't covered and your tier exception request is denied or still pending, you pay full retail — roughly $580/month, or $6,960/year — for that drug alone, on top of your Xarelto and lisinopril costs. None of that retail spending on a non-covered drug counts toward your $2,000 TrOOP cap, because TrOOP only counts payments for covered drugs.
Total annual cost in this scenario can exceed $7,500, even though your premium is low and even though the exact same drug was covered at $2,540 total on the plan in Scenario 2.
This is the trap we've documented before with Januvia and generic sitagliptin and with Eliquis GoodRx pricing: a $0-deductible or low-premium plan is meaningless if your specific drug isn't on formulary, and a pharmacy discount card doesn't count toward your Medicare cap the way an approved formulary fill does. The fix is a formal tier exception request submitted by your doctor before you fill the prescription — not after you've already paid retail for three months.
Preferred pharmacy and mail order: where the real savings live for people who don't hit the cap
If your drug list is lighter — say, just lisinopril and one moderate-cost brand — you may never reach the $2,000 cap at all. In that case, coinsurance percentage, preferred pharmacy status, and mail order fills are the entire game, because every dollar you save at the counter is a dollar you keep, not a dollar that simply shifts your catastrophic-phase start date.
- Preferred pharmacy networks often cut your coinsurance or copay by 10-20% compared to filling at an out-of-network or "standard" in-network pharmacy on the same plan.
- 90-day mail order fills frequently waive one month's worth of copay compared to three separate 30-day fills, and they reduce the number of times you're exposed to dispensing fees.
For beneficiaries who WILL hit the $2,000 cap (like our Xarelto/Farxiga example), preferred pharmacy and mail order mainly affect when you reach the cap — useful for smoothing your cash flow across the year, but not something that changes your final annual total once you're capped.
| Scenario | Monthly Premium | Deductible | Path to Cap | Annual Out-of-Pocket for Drugs | Total Annual Cost |
|---|---|---|---|---|---|
| Full Extra Help (LIS Level 1) | $0 | $0 | Fixed copays only | $350 | $350 |
| Standard plan, formulary-covered, standard pharmacy | $45 | $615 | 25% coinsurance to $2,000 (~month 6) | $2,000 | $2,540 |
| Standard plan, preferred pharmacy + mail order | $32 | $615 | 25% coinsurance to $2,000 (~month 4, better cash flow) | $2,000 | $2,384 |
| Standard plan, Farxiga non-formulary, exception denied | $45 | $615 | Full retail on Farxiga, no TrOOP credit | $6,960+ | $7,500+ |
This is the kind of analysis Pelandri runs for you — so you don't have to build the spreadsheet yourself. Feed in your actual drug list, dosages, ZIP code, and pharmacy preference, and the tool models every one of these scenarios against the real plans available where you live, using formulary and network data that mirrors what CMS publishes.
Why this matters more this Open Enrollment
The sandwich generation angle is worth naming directly: KFF Health News' recent HealthQ special on caregiving describes exactly the position many adult children are in right now — managing their own kids' schedules while also trying to figure out whether Mom's Part D plan still makes sense. Nobody sandwiched between two generations has the bandwidth to manually run TrOOP math against 25 formularies. That's not a failure of effort; it's a structural problem with how complicated the benefit has become, which is part of why MedPAC researchers are actively studying how beneficiaries respond to the post-redesign structure.
At the same time, affordability has become a defining kitchen-table issue in states like Nevada heading into the midterms, and that pressure is filtering down to individual households deciding whether they can afford their prescriptions this year. Whatever the broader policy debate, the actionable step for you right now is narrower and fully within your control: check whether you qualify for Extra Help, confirm your drugs are on formulary at the tier your plan assumes, and compare your preferred pharmacy's pricing against mail order.
You can model this for your specific situation at Pelandri — enter your exact drug list, including Xarelto, Farxiga, or whatever combination applies to you, and see the full-year cost breakdown across every plan in your ZIP code before Open Enrollment closes.
The bottom line
For Xarelto and Farxiga, the spread between the best and worst outcome isn't a rounding error — it's $350 versus $7,500 or more, depending entirely on three things you can control: whether you've applied for Extra Help, whether your plan's formulary covers both drugs without a fight, and whether you're using a preferred pharmacy with mail order. None of those show up in a plan's advertised premium. All of them show up in your December credit card statement.
If you take these drugs — or any high-cost brand combination — don't default to last year's plan. Run your specific list at Pelandri and see where you actually land before the enrollment window closes.
Sources
- Journalists Discuss Healthcare Costs’ Political Fallout, Concerns About Canceled ICE Facility — KFF Medicare
- Presentations by MedPAC staff at the 2026 AcademyHealth Annual Research Meeting and the 2026 Annual Conference of the American Society of Health Economists — MedPAC
- HealthQ Special: Caregiving in the Sandwich Generation — KFF Medicare
- New Disease Threats Follow Trump Administration’s Health Program Cuts — KFF Medicare
- Affordable Healthcare Emerges as a Voter Priority in Purple Nevada — KFF Medicare