Part D drug cap estimator

How does the 2026 cap work?

Since 2025, every Medicare drug plan, stand-alone 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. 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 your plan, for example at a pharmacy in Nuevo Laredo, Reynosa or Ciudad Juárez. Covered insulin is limited to $35 for a month's supply, and those payments count toward the cap. For more on crossing the border for care, see Medicare in Mexico.

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 Texas?

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 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 Texans. If you have full Texas Medicaid (including STAR+PLUS members), are in a Medicare Savings Program through HHSC (QMB, SLMB or QI-1), or get Supplemental Security Income, Medicare gives you Extra Help without a separate application. Read Texas 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 resource limit is higher than the Texas limit for Medicare Savings Programs, so some Texans who have too much in savings for a savings program still qualify for Extra Help.
• 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 how drug plans work in Texas and what to compare, see Medicare Part D in Texas. For 2027, 10 stand-alone Part D plans are offered statewide (CMS plan data). 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)
• HHSC MEPD Handbook — Q-1300, MSP resource limits

Frequently asked questions