question about Medicare 2025 negotiated drug prices

[JohnK924748]

My Xarelto prescription is included in the list of drugs which have Medicare's negotiated rates for 2026. The Maximum Fair Price (MFP) rate that I have seen is $197 per month.  My UHC prescription plan charged me $619.73 for 3 months ($206.57 per month). I've been trying to understand where the extra charge comes from. I read that the MFP should include all fees such as dispensing fees. Any clarification would be appreciated. Thanks

[jn85029821]

   I received my December 2025 prescription summary from my Part D insurer. Jardiance retailed at $1757.25 for a 90 tablet refill. I just tried to find the "new and improved" price for Jardiance. When I called my insurance company, I was informed that my cost would not change. They explained that I will always pay the co-pay listed in my insurance EOB. This leads me to believe that my Part D insurance company enjoys a price cut for Jardiance but that subscribers like me will continue to pay the same copay. Looks to me like Navitus (and other companies) may be benefiting more than the patience.   Am I wrong?  What am I missing?

[WilliamK556238]

But isn’t Jardiance diabetes medication? I thought diabetes meds and supplies were free under Part D…

[GailL1]

@WilliamK556238 

INSULIN [all types] under Part D plans are $ 35 for a month’s supply - Jardiance is NOT Insulin.

DRUGS.com-Jardiance 

[GailL1]

@jn85029821 

Your problem seems to be the new Jardiance price of $ 197 for a 30 day supply was ONLY effective 01/01/2026 - you said that you were looking at the December 2025 Rx Summary - it would have been the old price still at that point or $ 573.00 X 3 months = $ 1719.00 + your copay (looks like $ 12.75).

Beginning in 01/2026 the price for Medicare Prescription Drug Plans for Jardiance dropped to $ 197 for a 30 day supply.  

So the 1st 90-day refil in 2026 you will get it at $ 197 X 3 = $591.00 + your copay whatever it is based on the tier of Jardiance - that will be applied to your deductible of $ 615 and then the 2nd 90-day refill in 2026 will only be for your copay - If this is the only drug you have - then it will continue like this until you reach $ 2100 in out of pocket cost and then the insurer will pick up all the cost remaining in 2026. 

ICMS.gov - Medicare Drug Price Negotiation Program: Negotiated Prices for Initial Price Applicability... 

[GailL1]

@JohnK924748 , @flamingo163 

What is your plan?

What Tier is Xarelto in your plan?

What does your plan say about how much is the copay or co-insurance in your plan for this tier?

In the initial coverage phase, You 1st pay the deductible, then you pay any copay/coinsurance applicable to the drug or the drug’s tier.

Then did you get the drug at a preferred pharmacy?

[flamingo163]

I I have a similar question. My Xarelto refill cost me $207.43 today for a 30-day supply, higher than the $197 negotiated price. What exactly does the $197 refer to--the amount the plan pays for the drug, or the cap on the amount I pay? The insurance rep I called today provided no clarification except to say the price would go down after I satisfied my deductible.

[GailL1]

@flamingo163     What is your plan?  Does it have a deductible?  The max 2026 deductible for the plans that have one is $ 615.00 

What tier is Xarelto in your plan?  

1st you pay your deductible and then you pay whatever copay or coinsurance you have based on your plan - you pay this during your initial coverage phrase. Both will count towards your OOP of $ 2100 in 2026 as long as it is on your formulary for your 2026 plan.

You have a long way to go if you are buying Xarelto in 30 day increments unless your doc is prescribing it for one of the other more obscure reasons -

[JohnK924748]

Prior to posting to AARP, I contacted my UHC part D insurance provider and also contacted Medicare directly with out any resolution. I read a suggestion somewhere to contact my State Health Insurance Assistance Program (SHIP). So I sent them an email and was surprised when several days later they called me. They got my email and did some investigation. They mentioned that Medicare documentation is not completely clear, but they agreed that it SEEMED MFP pricing should include all fees; specifically they agreed that $197 per month is what I should have been charged. The asked me for some information and said they would contact Medicare because they suspect my email was the first of what will be many. They promised to get back to me. I will report here when  I hear something,

[SereneSeagull]

Have you tried pricing through discount programs not using Medicare drug plan at all?  You can get it much cheaper as I just checked with GoodRx and SingleCare discount codes  and it brings up the pharmacy prices around you

if you check both of those websites, plug in the name of med you can compare what it will be without using any insurance at all.  Majority of time way cheaper.  Most all pharmacies know this bit won’t offer.  Although cvs does a good job looking automatically to save you money, other places you need to ask for the given discount and provide name of the one you want them to run the price through on..  I use HIPPO for some and GoodRx for others.  

I realize this is not answering your given question, but thought I’d throw it out there

[JohnK924748]

Thank you for replying.

Yes, I have checked GoodRX. To clarify, the price I paid was because of my deductible, prices will be cheaper on the refills.

My question was more about how the negotiated pricing works and why the "list price" is higher than what I've seen reported as the negotiated price.