Medicare Drug Price Negotiation
Do negotiated drug prices count toward the $2,100 cap?
Last reviewed: · Big Sioux Benefits Data Desk
Yes. What you pay out of pocket for a drug with a negotiated price counts toward the $2,100 annual cap exactly as it would for any other covered Part D drug. Negotiation changes the drug's price; it does not create a separate accounting category. Your deductible payments and cost sharing on these drugs accumulate toward the threshold in the ordinary way.
The qualifier, and it confuses people because it sounds like bad news: because the drug costs less, your out-of-pocket spending on it accumulates more slowly, so you may reach the $2,100 cap later in the year than you would have before, or not at all. That is a better outcome, not a worse one. Reaching the cap is not a prize; it means you have already spent $2,100. Not reaching it means you spent less than that for the whole year.
The same person, before and after a price cut
| At the old list price | At the negotiated price | |
|---|---|---|
| Drug cost per month | Higher | Lower |
| Your cost sharing per fill | Higher if coinsurance | Lower if coinsurance |
| Speed you approach the cap | Faster | Slower |
| When you pay $0 | Earlier in the year | Later, or not at all |
| Your total for the year | Up to $2,100 | Possibly well under $2,100 |
Eliquis is the clean example. At the negotiated price, a full year on it runs roughly $1,154 in out-of-pocket cost under the standard benefit, which never reaches the cap. At the old list price the same person would have approached $2,100. Same drug, same plan design, several hundred dollars different. The full math is in how much Eliquis costs with Medicare, and what does and does not count toward the cap is in the 2026 drug cost cap.
Sources
- CMS — Medicare Drug Price Negotiation Program: Negotiated Prices for Initial Price Applicability Year 2026 — prices effective January 1, 2026; accessed 2026-08-21
- CMS — Announcement of Calendar Year 2026 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies (Part D benefit parameters) — CY2026 parameters; accessed 2026-08-21
- Medicare.gov — Costs for Medicare drug coverage — accessed 2026-08-21
Related questions
Is it bad that I no longer reach the $2,100 cap?
No, it is good. Reaching the cap means you have spent $2,100 out of pocket. Not reaching it means your total drug spending for the year was less than that. The cap is a ceiling on your losses, not a benefit you want to unlock.
Does the amount Medicare saves count toward my cap?
No. Only your own out-of-pocket spending counts, along with certain payments made on your behalf such as through Extra Help. What Medicare or your plan pays for the drug does not count toward your personal $2,100 threshold.
Drug costs turn on your specific prescriptions, so the arithmetic is worth doing once, properly: book a free, no-pressure conversation, see your county's South Dakota plan lineup, or browse all answers. SHIINE, the state's free counseling program, is at 1-800-536-8197 and sells nothing.
Big Sioux Benefits is a licensed insurance agency, not affiliated with or endorsed by the U.S. government or the federal Medicare program. We do not offer every plan available in your area. Contact Medicare.gov, 1-800-MEDICARE, or SHIINE (South Dakota's SHIP) for all of your options.