How Medicare drug coverage works
Medicare splits drug coverage between two parts:
- Part D covers most prescription drugs you take at home: pills, inhalers and pens or syringes you inject yourself. You get it from a standalone Part D plan (with Original Medicare) or from a Medicare Advantage plan that includes drug coverage. Each plan has its own formulary (drug list), tiers, pharmacy network and rules such as prior authorization.
- Part B covers drugs you don't usually give yourself, given in a doctor's office or hospital outpatient setting, such as eye injections (Eylea, Lucentis) and many infusions, plus drugs used with equipment like a nebulizer or an insulin pump.
The same drug can fall under either part depending on how it's given. Stelara is an example: the IV starting dose in a clinic is Part B, and the injections you give yourself at home are Part D.
What changes for drug coverage in 2027
- Part D out-of-pocket cap: $2,400, up from $2,100 in 2026. After you reach it, covered Part D drugs cost you nothing more for the rest of the year.
- Maximum Part D deductible: $700.
- Insulin stays capped at $35 for a one-month supply of each covered insulin, with no deductible.
- 15 more drugs get Medicare negotiated prices on January 1, 2027, from CMS's second round, including Ozempic, Wegovy, Trelegy Ellipta and Otezla. Stelara and Xarelto (along with Entresto and NovoLog/Fiasp) leave the program on the same date because a biosimilar or generic is now marketed.
- Medicare GLP-1 Bridge, which started July 1, 2026, is extended through December 31, 2027, for certain weight-management drugs.
- Adult vaccines recommended by the CDC's advisory committee, such as shingles and RSV, cost $0 under Part D.
The 24 drugs
Each page answers "Does Medicare cover it in Oregon?": which part covers it, its negotiation status, generics or biosimilars FDA has approved, the cost protections that apply and how to check a plan.
| Drug | Used for | Part | Medicare negotiation |
|---|---|---|---|
| Eliquis (apixaban) | atrial fibrillation, blood clots (DVT, PE) | D | Negotiated price since 2026 |
| Xarelto (rivaroxaban) | atrial fibrillation, blood clots, heart and artery disease | D | Negotiated price 2026 only; removed 2027 |
| Jardiance (empagliflozin) | type 2 diabetes, heart failure, kidney disease | D | Negotiated price since 2026 |
| Farxiga (dapagliflozin) | type 2 diabetes, heart failure, kidney disease | D | Negotiated price since 2026 |
| Januvia (sitagliptin) | type 2 diabetes | D | Negotiated price since 2026 |
| Ozempic (semaglutide) | type 2 diabetes (not covered for weight loss alone) | D | Negotiated price from 2027 |
| Wegovy (semaglutide) | heart-risk reduction, weight management, MASH | D | Negotiated price from 2027; GLP-1 Bridge |
| Mounjaro (tirzepatide) | type 2 diabetes | D | Not selected |
| Trulicity (dulaglutide) | type 2 diabetes | D | Selected for 2028 |
| Lantus (insulin glargine) | type 1 and type 2 diabetes | D | Not selected; insulin cap applies |
| Humira (adalimumab) | rheumatoid arthritis, Crohn's, colitis, psoriasis and more | D | Not selected; biosimilars available |
| Enbrel (etanercept) | rheumatoid and psoriatic arthritis, psoriasis | D | Negotiated price since 2026 |
| Stelara (ustekinumab) | psoriasis, psoriatic arthritis, Crohn's, colitis | D and B | Negotiated price 2026 only; removed 2027 |
| Otezla (apremilast) | psoriasis, psoriatic arthritis, Behçet's mouth ulcers | D | Negotiated price from 2027 |
| Eylea (aflibercept) | wet macular degeneration, diabetic eye disease | B | Not selected |
| Lucentis (ranibizumab) | wet macular degeneration, diabetic eye disease | B | Not selected |
| Imbruvica (ibrutinib) | CLL/SLL, Waldenström's, chronic GVHD | D | Negotiated price since 2026 |
| Revlimid (lenalidomide) | multiple myeloma, MDS, lymphomas | D | Not selected; generic available |
| Repatha (evolocumab) | high LDL cholesterol, heart-risk reduction | D | Not selected |
| Latuda (lurasidone) | schizophrenia, bipolar depression | D | Not selected; generic available |
| Lyrica (pregabalin) | nerve pain, fibromyalgia, seizures | D | Not selected; generic available |
| Spiriva (tiotropium) | COPD, asthma (Respimat) | D | Not selected |
| Symbicort (budesonide/formoterol) | asthma, COPD | D | Not selected; generic available |
| Trelegy Ellipta (fluticasone/umeclidinium/vilanterol) | COPD, asthma | D | Negotiated price from 2027 |
"Negotiated price" means CMS set a maximum fair price under the Medicare Drug Price Negotiation Program. It's what plans and pharmacies pay, not your copay. CMS selected 15 more drugs in January 2026, including Trulicity, for prices that take effect in 2028.
Drug coverage in Oregon
Oregon and Washington share Part D region 30. For 2027, Oregon has 8 standalone Part D plans from 4 companies, and 61 Medicare Advantage plans open to everyone are offered across the state, though not in every county. CMS data show no Medicare Advantage plan open to everyone in Grant, Harney, Lake, Umatilla or Union counties for 2027, so drug coverage there usually comes from a standalone Part D plan. See Oregon counties and Medicare Part D in Oregon.
If you have OHP and Medicare, OHP doesn't pay for drugs Part D covers ("OHP with Limited Drug"), so you need Part D coverage, and you qualify for Extra Help automatically. If your plan is ending, see plans ending in 2027.
How to check a plan's coverage for your drugs
- List every drug. Exact name, strength and how often you take it.
- Look them up. Enter them with your ZIP code on PlanMatch or Medicare.gov's Plan Finder to see each plan's formulary and rules.
- Read your 2027 Annual Notice of Change. It lists formulary changes for next year. Open Enrollment runs October 15 to December 7, 2026.
- Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.
If your drug isn't covered or a charge looks wrong
- Ask your plan for an exception. A formulary exception if the drug isn't covered, or a tiering exception if it's on a high tier. Your prescriber supports the request. See appealing a Medicare denial.
- Medicare questions: 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) or Medicare.gov.
- Suspected billing errors or fraud: the national Senior Medicare Patrol Resource Center, 1-877-808-2468. See reporting Medicare fraud.
- Extra Help applications: Social Security, 1-800-772-1213. See Extra Help in Oregon.
Sources
- Medicare.gov — Drug coverage (Part D)
- Medicare.gov — Prescription drugs (outpatient) under Part B
- CMS — CY 2027 Rate Announcement (2027 Part D deductible and out-of-pocket threshold)
- CMS — Selected drugs and negotiated prices
- CMS — Selected drugs for initial price applicability year 2028 (January 2026)
- CMS — Medicare GLP-1 Bridge
- Medicare.gov — Medicare Prescription Payment Plan
- Social Security — Extra Help with Medicare prescription drug plan costs
- Oregon Health Authority — OHP and Medicare
- CMS — Part D plan files record layout (PDP Region 30: Oregon, Washington)
Frequently asked questions
Is my drug covered by Medicare?
It depends on your plan. Each Part D plan and Medicare Advantage plan with drug coverage has its own formulary. Look up your exact drug and dose on each plan, and if it isn't covered, ask for a formulary exception with your prescriber's support.
What's the difference between Part B drugs and Part D drugs?
Part B covers drugs a clinician gives you in a doctor's office or outpatient setting, like eye injections and many infusions, plus drugs used with equipment such as a nebulizer or insulin pump. Part D covers drugs you take at home, like pills, inhalers and self-injected pens.
What's the 2027 Part D out-of-pocket cap?
It's $2,400 in 2027, up from $2,100 in 2026. Once what you pay for covered Part D drugs reaches the cap, you pay nothing more for covered Part D drugs the rest of the year. It doesn't apply to Part B drugs.
Does insulin still have a monthly cap?
Yes. Federal law caps what you pay for each covered insulin at $35 for a one-month supply, with no deductible, under Part D, and for insulin used with a covered pump under Part B.
Can I get help paying for prescriptions in Oregon?
Yes. Extra Help lowers Part D premiums, deductibles and copays for people with limited income and resources. You get it automatically with OHP, a Medicare Savings Program or SSI; otherwise apply through Social Security at 1-800-772-1213.
Medicare in your Oregon county
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