Medicare and your medication

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This page covers Medicare only. You may have insurance through a job, coverage bought on healthcare.gov, or Medicaid. If so, the explanations below still help. But the numbers will not apply to you.

Open Enrollment starts October 15. What changes for 2027

• Part D cap: now $2,400. It was $2,100 in 2026. The Part D deductible can now be up to $700. It was $615. Infusions are still outside the cap.
• Stand-alone drug plan premiums are likely to rise. The federal program that held them down in 2025 and 2026 ends this year. Check yours in the Annual Notice of Change. It arrives by September 30.
• Some Advantage plans are leaving for 2027. If yours is leaving, you have a guaranteed right to buy a supplement policy. There is a deadline.
• Part B premium and deductible for 2027 are announced in mid-November.

Switching plans: the dates, the rules, and the order to do it in →

Guides

Some subjects need their own page. One is how the approval process works. Others are single medications that come in more than one form. Medicare pays for those forms in very 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 drug bill Medicare does not cover.
• 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.
• Switching plans: the dates, the rules, and the order to do it in →
  Open Enrollment is October 15 to December 7. When an insurer must sell you a supplement policy, the order to do things in so you are never without coverage, and what changes on January 1, 2027.
• 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 sorts medications by who puts them in you. It does not sort them by what they are or what they cost.

• Part B covers medications a nurse or doctor gives you. That means infusions and most office injections. You pay 20% of the cost, every time, with no yearly ceiling.
• Part D covers medications you take yourself. That means 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. It rises to $2,400 in 2027. The cap holds no matter how expensive the medication is.

Take abatacept. Given as an infusion in the office, it is Part B. It has no ceiling. The same medicine as a self-injection at home is Part D. It stops at $2,100. Same drug, same disease. The difference can run to thousands of dollars a year. Where the medicine goes in decides it.

Ask your rheumatologist about this. 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?

The $2,100 cap only applies to Part D. 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. There, you owe 20% of the cost every time. And there is no yearly ceiling at all.

It is the same Medicare. It is often the same drug and the same disease. Who puts the medicine in you picks the rule book. The cap and the Part B coinsurance (your 20%) are two separate rules. News about one does not change the other.

Here is an example. Say Medicare’s approved amount for a year of your infusions is $18,000. You owe about $3,600. That is 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. In most states, the window to buy one closes six months after you enroll in Part B.
• A Medicare Advantage plan’s yearly out-of-pocket maximum. That is the most you pay in a year. It applies to everything the plan covers. But it comes with prior authorization attached. That means the plan must approve a medication before you can get it.
• QMB, a Medicare Savings Program. It removes the 20% entirely. QMB and Extra Help are different programs. Extra Help applies to Part D drugs only. It 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. It also may not make you try and fail a cheaper medication first. There is nothing to approve. Your rheumatologist decides, and the infusion happens.

Medicare Advantage plans may do both, and they do. 94% of Advantage enrollees are in a plan that requires prior authorization for medications like these. Most of those plans also use step therapy. That means trying a cheaper drug first. In 2024, Advantage plans made 52.8 million prior authorization decisions. They 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. It never appears in a price comparison. If your medication is turned down, appeal. The odds are good, and few people appeal.

One 2026 change, and what it does not affect

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

Here is what it covers. WISeR does not apply to any medication. It applies to a short list of procedures and devices. The list includes spinal cord stimulators, cervical fusion, and certain knee procedures. It also includes 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. They are excluded in Washington and Arizona.

So the statement above still holds. It holds for people in Washington too. Say you are on Original Medicare. Your medication is given in a doctor’s office. Then no one has to approve it in advance.

Buying a Medicare supplement: the six-month window

You get six months after you turn 65 and enroll in Part B. In that window, any company must sell you a Medicare supplement policy at the standard price. It does not matter what conditions you have. After the window closes, most states let insurers ask health questions and refuse you. Someone taking a biologic is exactly who gets refused.

You can change Advantage plans every year. You may not be able to get a supplement later at all. This is the key point 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 are asked. Insurers may not price by age. Connecticut, Massachusetts, New York and Maine have their own versions. Most other states do not.

Your window may have closed. Even then, in some situations an insurer must still sell you a policy. One is your plan leaving your county. Another is your first year in an Advantage plan. There is also a right order to do things in. The switching guide lists them.

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

Every state funds trained volunteer counselors. They go through your real options with you, free. They are paid nothing no matter what you choose. That is not true of the companies that advertise Medicare plans. CMS caps what a Medicare Advantage plan may pay a broker for signing you up. For 2026 that is $694 nationally for a new enrollment. It is $347 for each year you stay. A stand-alone drug plan pays $114. Medigap commissions are not set by CMS at all. Each state regulates them. They are usually a percentage of your premium. So there is no national figure to compare against. Nobody is paid anything for helping you stay in Original Medicare.

• 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. Few people who qualify use it. The income limits are higher than many people expect.
• Medicare directly — 1-800-MEDICARE (1-800-633-4227), any hour

What this page cannot tell you

This page has limits. A confident wrong number is worse than no number.

• Most drug prices here are estimates. They are the least reliable figures on the page. Some medications have their own guide above. For those, the figures were checked against Medicare’s published payment rates and the manufacturer’s published price. Everywhere else they are rough estimates.
• It does not know your plan. It cannot see your deductible or what you have already spent this year. It cannot see whether your medication is on your plan’s list.
• Supplement prices vary a lot 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. It shows which direction the money runs. 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 permissible in-network cost sharing for Part B drugs in Medicare Advantage for 2026: 20% coinsurance, or a copayment no greater than $340 for the “Part B Drugs — Other” service category ($395 for chemotherapy and radiation drugs). Plan bids may not exceed these amounts — CMS, “Final Contract Year 2026 Standards for Part C Benefits, Bid Review and Evaluation,” HPMS memorandum, April 16, 2025, Table 4; 42 CFR §422.100(f). The same memorandum sets the 2026 maximum out-of-pocket limits at $9,250 in-network and, for PPO plans, $13,900 combined (Table 3).
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.
13. Medicare Advantage and Part D broker compensation for 2026 ($694 initial and $347 renewal nationally for Medicare Advantage; $114 and $57 for a stand-alone Part D plan) — CMS, “Contract Year 2026 Agent and Broker Compensation Rates, Referral/Finder’s Fees, Submissions, and Training and Testing Requirements,” HPMS memorandum, June 18, 2025; 42 CFR §422.2274(d). Medicare supplement commissions are set by carriers and regulated by the states; no national figure is published.

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.

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