Medicare's rules are national, but how you use them for a specific condition depends on where your specialists are, whether you have Original Medicare or a Medicare Advantage plan, and which drugs you take. Each guide below covers what Medicare pays for, what it doesn't, and what to check when you choose coverage in Oregon.
Coverage by condition
Diabetes
Insulin cost cap, supplies and CGMs, self-management training, nutrition therapy, eye and foot care.
Cancer care
Screenings, surgery, chemotherapy under Part B, oral cancer drugs under Part D, and hospice.
Heart disease
Screenings, procedures, cardiac rehabilitation and heart medicines with negotiated prices.
Kidney disease and ESRD
Medicare under 65 for ESRD, dialysis, transplant and lifetime immunosuppressive drug coverage.
Dementia and Alzheimer's
Cognitive assessments, amyloid drugs, what Medicare doesn't cover, and Oregon long-term care help.
COPD and lung disease
Pulmonary rehab, inhalers, home oxygen, lung cancer screening and wildfire smoke.
What changed for drug costs
- Part D out-of-pocket cap: $2,400 in 2027 ($2,100 in 2026). After you reach it, covered Part D drugs cost nothing for the rest of the year.
- Insulin: no more than $35 for a month's supply of each covered insulin, under Part D or Part B (for insulin used with a pump).
- Medicare Prescription Payment Plan: lets you spread your Part D costs into monthly payments over the year. See what is the Medicare Prescription Payment Plan?
- Negotiated prices: CMS's first 10 negotiated prices took effect January 1, 2026, and 15 more take effect January 1, 2027 (see the table below). Negotiated prices change what plans pay; your own cost still depends on your plan's formulary and cost sharing.
- Extra Help: if your income and resources are limited, Extra Help lowers premiums and copays.
| Negotiated prices start | Drugs (as listed by CMS) |
|---|---|
| January 1, 2026 | Eliquis, Enbrel, Entresto, Farxiga, Imbruvica, Januvia, Jardiance, NovoLog/Fiasp, Stelara, Xarelto |
| January 1, 2027 | Austedo, Breo Ellipta, Calquence, Ibrance, Janumet, Linzess, Ofev, Otezla, Ozempic/Rybelsus/Wegovy, Pomalyst, Tradjenta, Trelegy Ellipta, Vraylar, Xifaxan, Xtandi |
CMS lists Stelara, Entresto, Xarelto and NovoLog/Fiasp as removed from the negotiated list effective January 1, 2027. To check how a plan covers your drugs, see the drug coverage guides or check plans for your drugs.
Original Medicare vs. Medicare Advantage with a chronic condition
- Original Medicare: any doctor or hospital in the U.S. that accepts Medicare, no referrals and no plan prior authorization. After the Part B deductible ($283 in 2026; CMS announces 2027 in the fall) you generally pay 20%, with no yearly limit unless you add a Medigap policy. Drug coverage comes from a separate Part D plan.
- Medicare Advantage: plans use networks and may require prior authorization for some services, but each has a yearly out-of-pocket limit for covered services (no more than $9,850 in network in 2027). Most include Part D. Medicare Advantage plans may offer extra benefits such as dental, vision, hearing or fitness. Extra benefits vary by plan and county, may have limits and costs, and not every plan offers them. Check a plan's Summary of Benefits or Evidence of Coverage.
Before you choose, confirm that your specialists, your hospital and any cancer, transplant or dialysis center you use are covered. Some Oregon counties have few or no Medicare Advantage plans open to everyone; see Medicare in rural Oregon. Some special needs plans are for people with specific chronic conditions; availability varies by county.
Where to get help
- 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048): what Medicare covers for your condition.
- Your plan: coverage rules, prior authorization and formulary exceptions. If a plan denies care, see Medicare appeals in Oregon.
- A licensed insurance agent: to compare plans from the companies they work with against your doctors and drugs, you can request a call from a licensed insurance agent or meet licensed insurance agents in Oregon.
Related guides
Drug coverage guides
Common drugs A to Z and Part D basics.
Original Medicare vs. Advantage
Side by side for Oregon.
Medicare costs in 2027
The amounts CMS has published.
Sources
- CMS — Selected drugs and negotiated prices
- CMS — CY 2027 Rate Announcement (2027 Part D parameters)
- Medicare.gov — What Medicare drug plans cover
- Medicare.gov — Medicare costs
Frequently asked questions
What is the Part D out-of-pocket cap for 2027?
$2,400 for covered Part D drugs in 2027, up from $2,100 in 2026. Once you reach it, you pay nothing more for covered Part D drugs for the rest of the year.
Which drugs have Medicare-negotiated prices?
CMS negotiated prices for 10 drugs starting January 1, 2026, including Eliquis, Jardiance, Farxiga, Januvia and Imbruvica, and for 15 more starting January 1, 2027, including Ozempic, Rybelsus, Wegovy, Trelegy Ellipta, Breo Ellipta, Ibrance and Xtandi. What you pay still depends on your plan.
Is Original Medicare or Medicare Advantage better for a serious condition?
It depends on your doctors and how you get care. Original Medicare works with any provider that accepts Medicare and doesn't use plan prior authorization; a Medigap policy can help with its cost sharing. Medicare Advantage plans use networks and may require prior authorization, but include a yearly out-of-pocket limit. Check that your specialists and hospital are covered before you choose.
Medicare in your Oregon county
Plans, local agents and help, county by county: Multnomah · Washington · Clackamas · Lane · Marion · Jackson · Deschutes · Linn · Douglas · Yamhill · Benton · Polk · Josephine · Umatilla · Klamath · Coos · Columbia · Lincoln · Clatsop · Malheur · All 36 counties →
