Medicare and your medication

Start here

This covers Medicare only. If you have insurance through a job, coverage bought on healthcare.gov, or Medicaid, the explanations below are still useful but the numbers will not apply to you.

Guides

Some subjects have enough going on that they deserve their own page — how the approval process works, and individual medications that come in more than one form, because Medicare pays for those forms in completely different ways.

• Why your medicine needs permission first →
  Prior authorization explained in plain language — where it came from, who is really deciding, why your doctor and your plan keep telling you different things, and what to do when you are denied.
• Help paying for your medication →
  Extra Help does nothing for an infusion. QMB does. Which program covers which kind of drug, why your copay card stopped working, and what to do instead.
• Where you get infused changes the bill →
  Medicare pays a hospital three to four times what it pays a doctor’s office for the same infusion, and you owe 20% of the bigger number. Plus the surprise drug bill nobody warns you about.
• Helping a parent with all of this →
  You need four separate permissions and a power of attorney is not one of them. The forms, what to gather before you call, and what changes when a spouse dies.
• Infliximab (Remicade, Inflectra, Renflexis, Avsola) →
  Your plan may make you switch between versions of this one. The switch saves you about $190 a year — far less than the word "biosimilar" suggests.
• Rituximab (Rituxan, Truxima, Ruxience, Riabni) →
  Here the cheaper versions genuinely are much cheaper — a quarter of the price. The bills also arrive in a few very large lumps rather than monthly.
• Tocilizumab (Actemra) →
  The infusion and the self-injection cost very different amounts, and which one is cheaper depends on whether you have a supplement.
• Abatacept (Orencia) →
  On paper the self-injection is far cheaper than the infusion. In practice most drug plans do not cover it at all — so check before you count on it.
• Secukinumab (Cosentyx) →
  The pen and the infusion are paid for out of two different pockets. For most people on Medicare the pen costs thousands less — and it is widely covered.
• Golimumab (Simponi and Simponi Aria) →
  The self-injection is capped at $2,100 a year — but almost no Medicare drug plan covers it, so nearly everyone ends up on the infusion instead.

More medications are being added.

Why infusions and pills are treated completely differently

Medicare splits medications by who puts them in you, not by what they are or what they cost.

• Part B covers medications a nurse or doctor gives you — infusions and most office injections. You pay 20% of the cost, every time, with no yearly ceiling.
• Part D covers medications you take yourself — pills and injections you do at home. Since 2025, Part D has a hard cap on what you can be charged in a year: $2,100 in 2026, rising to $2,400 in 2027, no matter how expensive the medication is.

The result surprises people. Abatacept given as an infusion in the office is Part B and has no ceiling. The same medicine as a self-injection at home is Part D and stops at $2,100. Same drug, same disease, and the difference can run to thousands of dollars a year — decided entirely by where it goes in.

This is worth raising with your rheumatologist. Whether a home version is right for you is a medical question, not a money one.

Why isn’t my infusion covered by the $2,100 cap?

Because the $2,100 cap only applies to Part D, and an infusion is paid by Part B. The cap Congress created covers drugs you pick up and take yourself. A medication a nurse or doctor gives you is paid under Part B instead, where you owe 20% of the cost every time and there is no annual ceiling at all.

It is the same Medicare, often the same drug, and frequently the same disease. The rulebook is chosen by who puts the medicine in you. Almost everything written about the cap leaves this out, so people on infusions read that their costs are now limited, and then the bills keep coming.

A worked example. If Medicare’s approved amount for a year of your infusions is $18,000, you owe about $3,600 — this year, next year, and every year you stay on it. The $2,100 cap does not apply to any of it.

Four things do put a ceiling on Part B costs:

• A Medicare supplement (Medigap) policy, which pays the 20% for you. This is the main one, and the window to buy one closes six months after you enroll in Part B in most states.
• A Medicare Advantage plan’s yearly out-of-pocket maximum, which applies to everything the plan covers — though it comes with prior authorization attached.
• QMB, a Medicare Savings Program that eliminates the 20% entirely. This is the one people are not told about — and note that Extra Help, which people are told about, does nothing for a Part B drug.
• Full Medicaid, or retiree coverage that pays after Medicare.

Where prior authorization actually applies

Original Medicare does not require prior authorization for a medication given in a doctor’s office, and it is not permitted to make you try and fail a cheaper medication first. There is nothing to approve. Your rheumatologist decides, and the infusion happens.

Medicare Advantage plans are permitted to do both, and they do. 94% of Advantage enrollees are in a plan that requires prior authorization for medications like these, and most of those plans also apply step therapy. In 2024 Advantage plans made 52.8 million prior authorization decisions and denied 4.1 million of them. Only about one in nine denials was appealed — and 81% of the appeals succeeded.

That gap is the real cost of an Advantage plan for someone on an infused biologic, and it never appears in a price comparison. If your medication is turned down, appeal. The odds are good and most people never try.

One 2026 change, and what it does not affect

As of January 2026, CMS is running a pilot called WISeR that brings prior authorization into Original Medicare for the first time, using automated review, in six states — New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.

It is worth knowing about, and it is worth being precise about what it covers. WISeR does not apply to any medication. It applies to a short list of procedures and devices — spinal cord stimulators, cervical fusion, certain knee procedures, vertebral augmentation, nerve stimulators, epidural steroid injections for pain, and a few others. No infusion, no biologic, and no rheumatology drug is on the list. Skin and tissue substitutes are the one biological product included, and they are specifically excluded in Washington and Arizona.

So the statement above still holds, including for people in Washington: if you are on Original Medicare and your medication is given in a doctor’s office, no one has to approve it in advance.

The decision you can only make once

For six months after you turn 65 and enroll in Part B, any company must sell you a Medicare supplement policy at the standard price, no matter what conditions you have. Once that window closes, in most states insurers can review your health and refuse you — and someone taking a biologic is precisely who gets refused.

You can change Advantage plans every single year. Getting a supplement later, you may not be able to at all. That asymmetry is the single most important thing for anyone turning 65 right now.

Washington is the most protective state in the country on this. You can move between supplement policies at any time of year, no health questions asked, and insurers may not price by age. Connecticut, Massachusetts, New York and Maine have their own versions. Most other states do not.

Talk to a counselor before you talk to anyone selling you something

Every state funds trained volunteer counselors who will go through your actual options with you, free, and who are paid nothing regardless of what you choose. That is not true of the companies that advertise Medicare plans — brokers are paid roughly twice as much for enrolling you in an Advantage plan as for a supplement, and that commission renews every year you stay.

• In Washington: SHIBA — insurance.wa.gov/shiba or 1-800-562-6900
• Everywhere else: SHIP — shiphelp.org
• Confirm your medication is covered — medicare.gov/plan-compare is the only place that shows a specific plan’s drug list
• Help paying — if money is tight, look up Extra Help through Social Security. It is widely underused, and the income limits are higher than most people assume.
• Medicare directly — 1-800-MEDICARE (1-800-633-4227), any hour

What this page cannot tell you

It is worth being clear about the limits, because a confident wrong number is worse than no number.

• Most drug prices here are estimates. They are the least reliable figures on the page. Where a medication has its own guide above, the figures have been checked against Medicare’s published payment rates and the manufacturer’s published price; everywhere else they are approximations.
• It does not know your plan. It cannot see your deductible, what you have already spent this year, or whether your medication is on your plan’s list.
• Supplement prices vary enormously by state, age and company. The figures offered are placeholders, not quotes.
• Everything here is for 2026 and changes every January.

The purpose is not to hand you an exact number. It is to show you which questions to ask and which direction the money runs — and those parts are solid.

Where these figures come from

1. Part B standard premium ($202.90/month) and annual deductible ($283) for 2026 — CMS, “2026 Medicare Parts A & B Premiums and Deductibles,” November 14, 2025.
2. Part B coinsurance of 20% with no annual out-of-pocket limit — Social Security Act §1833(a); CMS, Medicare & You 2026.
3. Part D annual out-of-pocket cap ($2,100 in 2026; $2,400 in 2027) and deductible ($615) — CMS Final CY2026 Part D Redesign Program Instructions and the CY2027 Rate Announcement, April 2026. Cap established by the Inflation Reduction Act of 2022.
4. Part D base beneficiary premium ($38.99 for 2026) — CMS Part D national average monthly bid announcement, July 2025. Actual plan premiums vary widely.
5. Maximum Medicare Advantage copay per Part B drug administration ($340) and the 2026 in-network out-of-pocket maximum limits — CMS Final CY2026 Part C Bid Review Memorandum, April 2025.
6. Average in-network out-of-pocket limit among Medicare Advantage enrollees ($5,421 for 2026) — KFF, “Medicare Advantage in 2026,” 2026. This is an average, not a legal limit; plans may set limits up to $9,250 in-network.
7. 94% of Medicare Advantage enrollees in plans requiring prior authorization for Part B drugs; step therapy permitted in Medicare Advantage and not in Original Medicare — KFF, “Medicare Advantage in 2026”; 42 CFR §422.136.
8. 52.8 million prior authorization determinations, 4.1 million denials, 11.5% appeal rate and 80.7% of appeals overturned in 2024 — KFF analysis of CMS data, 2026.
9. Medigap six-month open enrollment period and medical underwriting after it — Social Security Act §1882(s)(2)(A); CMS, Choosing a Medigap Policy.
10. Washington State continuous Medigap open enrollment and community rating — RCW 48.66.045 and RCW 48.66.130.
11. WISeR model states, covered services and model period — CMS Innovation Center, WISeR Model, and the WISeR Provider and Supplier Operational Guide, July 2026.
12. Extra Help / Part D Low-Income Subsidy — Social Security Administration; CMS CY2026 LIS resource limits memorandum, October 2025.

About this page

Written and reviewed by Alison Bays, MD, MPH, board-certified rheumatologist. Figures are current for 2026 and were last checked in August 2026.

This is educational information, not advice — not medical, legal, financial or insurance advice, and not a substitute for talking to your doctor or your plan. Nothing is sold here. No insurance is sold here, no plan is recommended, and neither this page nor its author is paid by any insurance company, plan or broker. This page is not affiliated with, endorsed by, or connected to Medicare, the Centers for Medicare & Medicaid Services, or any government agency.

Nothing you enter is collected, stored, or transmitted. There is no form, no account and no tracking of what you type.

Found something wrong? Please tell us.