By Patricia Prewitt
My Personal Rx Adviser

I have been following with interest reports on the impact of the 2025 cap on out-of-pocket prescription costs from various healthcare sources, including government websites. The data is still emerging.
Remind me, what changed about the out-of-pocket cap in 2025 for Medicare enrollees?
Prior to 2025, there really was no annual limit on drug spending for people on Medicare. Some people were often paying $5,000-$10,000+ per year on medications. Costs were unpredictable, and often unaffordable. Starting in 2025, once the $2,000 cap was reached, a Medicare subscriber would pay $0 for covered medicines.
New for 2026: The out-of-pocket prescription cap increased slightly to $2,100 annually for covered medications.
That sounds great; but what’s the catch?
If the medication was not covered – like many lifestyle products for sexual health, weight loss, hair loss, and other products excluded from the Medicare Part D Plan formulary – the cap does not apply. It remains very important to understand what is covered under your Medicare Part D prescription plan-or Part C for the Medicare Advantage Plans.
What else should I understand about this cap?
People are often confused when medications are dispensed or infused in a clinic or hospital setting. Those medications generally fall under the Part B plan of Medicare, so the cap does not apply to those medications.
What does the data show for real impact? (KFF & Medicare)
Preliminary reports from Kaiser Family Foundation and Medicare estimated about 1.5 million people reached the $2,000 cap in 2025. Many people saved between $1,000-$3,000 annually. Some saved $5,000 a year or more. For 2026, a Medicare infographic from Centers for Medicare and Medicaid Services predicts 5.3 million Medicare enrollees will benefit in the year ahead.
Who are the people who benefit the most?
People with cancer, autoimmune disorders, neurological conditions, or lung conditions often have higher medication costs, since newer medications for those conditions are patent protected and expensive.
The Medicare prescription drug cap prevents financial disaster, but it doesn’t eliminate the need to be a smart consumer. Generically available medications remain the best way to manage prescription costs over time.
While statistics are interesting, my focus continues to be on pocket book results in real life. I am curious, what is your experience? Did your costs decrease during 2025 for your out-of-pocket prescriptions? If you want to share: Tricia@mypersonalrxadvisor.com.

Content provided is for educational purposes only and is not intended as a substitute for advice from a qualified medical professional. The opinions expressed within are those of the author.

About the Author: Patricia Prewitt is a local Massachusetts resident who spent more than 30 years in  the pharmaceutical industry. Tricia is a consumer education advocate, and loves helping people find ways to save money on their prescriptions. More information and free resources are available on her website at https://mypersonalrxadvisor.com/resources or call her at 508-507-8840. Favorite Quote: “Act as if what you do makes a difference. It does.” – William James