How does the 2026 cap work?
Since 2025, every Medicare drug plan, standalone or part of a Medicare Advantage plan, stops charging you for covered drugs once your own out-of-pocket spending reaches the yearly cap. In 2026 the cap is $2,100. 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. There is no longer a gap between those phases.
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 your plan. Covered insulin is limited to $35 for a month's supply, and those payments count toward the cap. In rural and Appalachian Ohio, where the nearest pharmacy may be a long drive, check that a plan's network includes a pharmacy you can reach, or that it offers mail order for your maintenance drugs; see rural and Appalachian Ohio.
Drug plans in Ohio
Ohio is its own Part D region, so standalone drug plans sold here are priced for Ohio. For 2027, CMS lists 9 standalone Part D plans in Ohio from 5 companies, plus drug coverage in most Medicare Advantage plans. Plans change their drug lists and costs every year, so check your prescriptions against each plan's formulary during the Annual Enrollment Period, which ends December 7, 2026. Ohio public retirees should check their system's rules before joining a separate drug plan: STRS Ohio warns that enrolling in any other Part D plan cancels your STRS Ohio medical and prescription coverage. See Medicare Part D in Ohio.
Can I spread the cost over the year?
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.
Who gets Extra Help in Ohio?
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. People with full Ohio Medicaid and income at or below the federal poverty level pay no more than $1.60 and $4.90. Extra Help can also pay all or part of your drug plan's premium.
- Automatic for many Ohioans. If you have full Ohio Medicaid (including MyCare Ohio), are in a Medicare Premium Assistance Program (QMB, SLMB or QI-1), or get Supplemental Security Income, Medicare gives you Extra Help without a separate application. Read Ohio Medicaid and Medicare.
- 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. That is higher than Ohio's premium assistance resource limit, so some Ohioans with too much in savings for those programs still qualify for Extra Help. Check both with the savings programs screener, and see Extra Help in Ohio.
- A chance to change plans. People with Extra Help can switch to a different drug plan once a month in some situations; see enrollment periods.
For 2027 the cap rises; see 2027 Part D amounts. To look at plans offered where you live, you can check your drugs against plans for 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)
- eCFR — 42 CFR 423.773, Requirements for eligibility (people treated as eligible for Extra Help)
- CMS — CY2027 Part D Landscape files (Ohio, PDP Region 14)
- STRS Ohio — Medicare enrollment (other Part D plans)
Frequently asked questions
What counts toward the $2,100 cap?
What you pay for covered Part D drugs: your deductible, copays and coinsurance. Your monthly plan premium doesn't count, and neither do drugs your plan doesn't cover. Payments Extra Help makes for you also count toward the cap.
Is insulin part of the cap?
Yes. Covered insulin costs no more than $35 for a month's supply, and what you pay for it counts toward the yearly cap.
What happens after I reach the cap?
You pay nothing more for covered Part D drugs for the rest of the calendar year. The cap starts over on January 1, and for 2027 it rises; see our 2027 costs page.
Does the cap apply to my STRS Ohio or SERS retiree drug coverage?
The group Medicare plans STRS Ohio and SERS offer include Part D coverage, and Part D's yearly out-of-pocket cap applies to Part D coverage. Your system's plan materials show how its drug coverage works and what you pay.
How do I get Extra Help in Ohio?
If you have full Ohio Medicaid, a Medicare Premium Assistance Program (QMB, SLMB or QI-1) or Supplemental Security Income, Medicare enrolls you automatically. Otherwise you apply with Social Security online or by phone. Extra Help has income and resource limits, which the savings programs screener on this site checks.
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