Part D drug cap estimator

How the 2026 cap works

Since 2025, Medicare drug plans, stand-alone or part of a Medicare Advantage plan, stop charging you for covered drugs once your own out-of-pocket spending reaches the yearly cap. In 2026 the cap is $2,100. There is no longer a coverage gap or "donut hole": the year has a deductible phase (up to $615 in 2026, and some plans charge less or none), then you share costs with your plan until you reach the cap, then you pay nothing for covered drugs.

The cap counts what you pay at the pharmacy for drugs on your plan's drug list. It doesn't count your monthly premium, drugs your plan doesn't cover, or drugs bought outside the U.S., for example at a pharmacy in Canada. Drugs you buy with a pharmacy discount card instead of your plan generally don't count either. Covered insulin is limited to $35 for a month's supply, and those payments count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

If an expensive prescription would have you pay most of the cap in January, you can join the Medicare Prescription Payment Plan through your drug plan. You then pay nothing at the pharmacy and get a monthly bill from your plan instead. The total is the same; the bills are spread over the rest of the year. The calculator's monthly figure assumes you join for the whole year; joining later in the year spreads the cost over fewer months.

The payment plan helps most when costs come early and are high. If you qualify for Extra Help, Extra Help usually helps more, because it lowers what you owe instead of spreading it out.

Extra Help for Washingtonians

Extra Help is the federal program that lowers Part D costs for people with limited income and resources. With Extra Help you pay no deductible and, in 2026, no more than $5.10 for a generic or $12.65 for a brand-name drug (less for some people with full Apple Health coverage). Extra Help can also pay all or part of your drug plan's premium.

• Automatic for many Washingtonians. If you have full Apple Health coverage or are in a Medicare Savings Program (QMB, SLMB or QI-1), Medicare gives you Extra Help without a separate application. Washington's Medicare Savings Programs have no asset test and reach higher incomes than the federal minimum, so they are worth checking first. Read Apple Health and Medicare and Medicare Savings Programs in Washington.
• Others apply with Social Security. In 2026 the income limit is $23,940 a year for one person or $32,460 for a married couple, and resources must be under $16,590 or $33,100. Unlike Washington's Medicare Savings Programs, Extra Help does count savings and investments. See Extra Help in Washington.
• A chance to change plans. People with Extra Help can switch to a different drug plan once a month in some situations; see when you can change your Medicare plan.

For how drug plans work in Washington and what to compare, see Medicare Part D in Washington and prescription drug costs. To look at plans offered where you live, you can see plans in your ZIP code.

Sources

• Medicare.gov — Costs for Medicare drug coverage
• Medicare.gov — Medicare Prescription Payment Plan
• Medicare.gov — Help with drug costs (Extra Help)
• Social Security — Extra Help with Medicare prescription drug costs
• CMS — CY 2026 resource and cost-sharing limits for the Low-Income Subsidy (PDF)
• Washington State Health Care Authority — Medicare Savings Program

Frequently asked questions