How Medicare drug coverage works
Medicare splits drug coverage between two parts:
- Part D covers most prescription drugs you take at home: pills, inhalers and pens or syringes you inject yourself. You get it from a standalone Part D plan (with Original Medicare) or from a Medicare Advantage plan that includes drug coverage. Each plan has its own formulary (drug list), tiers, pharmacy network and rules such as prior authorization.
- Part B covers a limited set of outpatient drugs, mostly ones you don't usually give yourself, such as injections and infusions a clinician gives in a doctor's office or hospital outpatient setting (Eylea eye injections, for example), plus drugs used with equipment like a nebulizer or an insulin pump, and certain injectable osteoporosis drugs.
The same drug can fall under either part depending on how it's given. Stelara is an example: the IV starting dose in a clinic is Part B, and the injections you give yourself at home are Part D. Part A covers drugs only as part of an inpatient stay.
What changes for drug coverage in 2027
- Part D out-of-pocket cap: $2,400, up from $2,100 in 2026. After you reach it, covered Part D drugs cost you nothing more for the rest of the year.
- Maximum Part D deductible: $700.
- Insulin stays capped at $35 for a one-month supply of each covered insulin, with no deductible.
- 15 more drugs get Medicare negotiated prices on January 1, 2027, from CMS's second round, including Ozempic, Wegovy and Rybelsus (semaglutide), Trelegy Ellipta and Otezla. Stelara, Xarelto, Entresto and NovoLog/Fiasp leave the program on the same date because a generic or biosimilar is now marketed.
- Medicare GLP-1 Bridge, which started July 1, 2026, runs through December 31, 2027, for certain weight-management drugs.
- Adult vaccines recommended by the CDC's advisory committee (ACIP), such as shingles and RSV, cost $0 under Part D, with no deductible.
The 24 drugs
Each page answers "Does Medicare cover it in Ohio?": which part covers it, its negotiation status, generics or biosimilars, the cost protections that apply and how to check a plan.
| Drug | Used for | Part | Medicare negotiation |
|---|---|---|---|
| Eliquis (apixaban) | atrial fibrillation, blood clots (DVT, PE) | D | Negotiated price since 2026 |
| Xarelto (rivaroxaban) | atrial fibrillation, blood clots, heart and artery disease | D | Negotiated price 2026 only; removed 2027 |
| Entresto (sacubitril/valsartan) | heart failure | D | Negotiated price 2026 only; removed 2027 |
| Jardiance (empagliflozin) | type 2 diabetes, heart failure, kidney disease | D | Negotiated price since 2026 |
| Farxiga (dapagliflozin) | type 2 diabetes, heart failure, kidney disease | D | Negotiated price since 2026 |
| Januvia (sitagliptin) | type 2 diabetes | D | Negotiated price since 2026 |
| Ozempic (semaglutide) | type 2 diabetes (not covered for weight loss alone) | D | Negotiated price from 2027 |
| Wegovy (semaglutide) | heart-risk reduction, weight management, MASH | D | Negotiated price from 2027; GLP-1 Bridge |
| Mounjaro (tirzepatide) | type 2 diabetes | D | Not selected |
| Zepbound (tirzepatide) | sleep apnea with obesity, weight management | D | Not selected; KwikPen in GLP-1 Bridge |
| Trulicity (dulaglutide) | type 2 diabetes | D | Selected for 2028 |
| Lantus (insulin glargine) | type 1 and type 2 diabetes | D | Not selected; insulin cap applies |
| Enbrel (etanercept) | rheumatoid and psoriatic arthritis, psoriasis | D | Negotiated price since 2026 |
| Humira (adalimumab) | rheumatoid arthritis, Crohn's, colitis, psoriasis and more | D | Not selected; biosimilars available |
| Stelara (ustekinumab) | psoriasis, psoriatic arthritis, Crohn's, colitis | D and B | Negotiated price 2026 only; removed 2027 |
| Otezla (apremilast) | psoriasis, psoriatic arthritis, Behçet's mouth ulcers | D | Negotiated price from 2027 |
| Imbruvica (ibrutinib) | CLL/SLL, Waldenström's, chronic GVHD | D | Negotiated price since 2026 |
| Repatha (evolocumab) | high LDL cholesterol, heart-risk reduction | D | Not selected |
| Trelegy Ellipta (fluticasone/umeclidinium/vilanterol) | COPD, asthma | D | Negotiated price from 2027 |
| Spiriva (tiotropium) | COPD, asthma (Respimat) | D | Not selected |
| Symbicort (budesonide/formoterol) | asthma, COPD | D | Not selected |
| Prolia (denosumab) | osteoporosis | B or D, depending on who gives it | Not selected |
| Eylea (aflibercept) | wet macular degeneration, diabetic eye disease | B | Not selected |
| Shingrix (shingles vaccine) | preventing shingles | D | Not applicable; $0 as an ACIP-recommended vaccine |
"Negotiated price" means CMS set a maximum fair price under the Medicare Drug Price Negotiation Program. It's what plans and pharmacies pay, not your copay. In January 2026 CMS selected 15 more drugs, including Trulicity, for prices that take effect in 2028. See Which drugs have Medicare negotiated prices in 2027?
Drug coverage in Ohio
Ohio is its own Part D region (PDP Region 14), so each standalone Part D plan sold in Ohio is offered in all 88 counties. For 2027, CMS lists 9 standalone Part D plans from 5 companies, and 119 Medicare Advantage plans open to everyone are offered across the state; CMS data show Medicare Advantage plans with drug coverage in every county. See How many Part D plans are in Ohio for 2027? and Ohio counties.
Ohio has no state pharmaceutical assistance program that pays toward Medicare drug costs, and the Golden Buckeye card is a discount card for businesses, not drug coverage. The help that exists is mostly federal: Extra Help, the Medicare Prescription Payment Plan and, for people with full Ohio Medicaid, Medicare drug coverage with Extra Help built in (in MyCare Ohio, often through the same plan as Medicaid). See Does Ohio have a prescription assistance program for seniors? If your Medicare Advantage plan is ending, see plans ending in 2027.
How to check a plan's coverage for your drugs
- List every drug. Exact name, strength and how often you take it.
- Look them up. Enter them with your ZIP code on PlanMatch or Medicare.gov's Plan Finder to see each plan's formulary and rules.
- Read your 2027 Annual Notice of Change. It lists formulary changes for next year. Open Enrollment runs October 15 to December 7, 2026.
- Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.
If your drug isn't covered or a charge looks wrong
- Ask your plan for an exception. A formulary exception if the drug isn't covered, or a tiering exception if it's on a high tier. Your prescriber supports the request. See appealing a Medicare denial.
- Medicare questions: 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) or Medicare.gov.
- Suspected billing errors or fraud: the Ohio Senior Medicare Patrol, run by Pro Seniors, Inc., at 1-800-293-4767. See Medicare fraud in Ohio.
- Extra Help applications: Social Security, 1-800-772-1213 (TTY 1-800-325-0778). See Extra Help in Ohio.
Sources
- Medicare.gov — Drug coverage (Part D)
- Medicare.gov — How much does Medicare drug coverage cost?
- Medicare.gov — Prescription drugs (outpatient) under Part B
- Medicare.gov — Shingles vaccines
- CMS — CY 2027 Rate Announcement (2027 Part D deductible and out-of-pocket threshold)
- CMS — Selected drugs and negotiated prices (including drugs with deselection determinations)
- CMS — Selected drugs for initial price applicability year 2028 (January 2026)
- CMS — Medicare GLP-1 Bridge
- Medicare.gov — Weight loss drugs (Medicare GLP-1 Bridge)
- Medicare.gov — Medicare Prescription Payment Plan
- Social Security — Extra Help with Medicare prescription drug plan costs
- CMS — Medicare Advantage and Part D Landscape files, 2027 (PDP Region 14: Ohio)
- Ohio Revised Code — Section 173.06, Golden Buckeye card program
Frequently asked questions
Is my drug covered by Medicare?
It depends on your plan. Each Part D plan and Medicare Advantage plan with drug coverage has its own formulary. Look up your exact drug and dose on each plan, and if it isn't covered, ask for a formulary exception with your prescriber's support.
What's the difference between Part B drugs and Part D drugs?
Part B covers drugs a clinician gives you in a doctor's office or outpatient setting, like eye injections and many infusions, plus drugs used with equipment such as a nebulizer or insulin pump. Part D covers drugs you take at home, like pills, inhalers and self-injected pens.
What's the 2027 Part D out-of-pocket cap?
It's $2,400 in 2027, up from $2,100 in 2026. Once what you pay for covered Part D drugs reaches the cap, you pay nothing more for covered Part D drugs the rest of the year. It doesn't apply to Part B drugs.
Does Ohio have its own prescription drug program for seniors?
Ohio has no state pharmaceutical assistance program that pays for Medicare drug costs. The Golden Buckeye card offers business discounts, not drug coverage. Federal Extra Help is the main program that lowers Part D costs.
Can I get help paying for prescriptions in Ohio?
Yes. Extra Help lowers Part D premiums, deductibles and copays for people with limited income and resources. You get it automatically with Ohio Medicaid, a Medicare Premium Assistance Program or SSI; otherwise apply through Social Security at 1-800-772-1213.
Medicare in your Ohio county
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