Prescription medications can be difficult to keep up with financially, especially when needed to treat a chronic condition, like diabetes. Insulin in particular has suffered from skyrocketing prices over the past few years. Fortunately, as of January 2021, Medicare introduced the Senior Savings Model to place a hard cap on insulin prices in participating Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... plans.
In this MedicareWireMedicareWire is a Medicare insurance consulting agency. We founded MedicareWire after seeing and hearing how confusing and frustrating it is to find, understand, and choose a plan. Our services are free to the consumer. article, we’ll explain how the Senior Savings Model works and how much insulin costs with a participating Medicare Part D plan. We’ll also explain how you can get help with the remaining costs after your Medicare Part D plan has paid its share.
- Insulin is used to maintain a healthy blood sugar level when your body cannot produce a sufficient amount on its own.
- Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. do not cover insulin unless it is for use with an insulin pump.
- Enhanced Medicare Part D plans participating in the Senior Savings Model program help limit a month’s supply of insulin to $35.
- Medicare Part D plans will also cover insulin injection supplies for a small copayment.
- Medicare Advantage PlansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). that come with Part D drug coverage will also cover a monthly supply of insulin for its members.
- Part D plan members that need Extra Help with out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. for prescription drugs may qualify for Social Security’s Low-Income SubsidySocial Security's Low-Income Subsidy (LIS) program helps Medicare beneficiaries pay for their Medicare Part D prescription drugs by paying some of the costs. Also known as "Extra Help", beneficiaries who qualify for LIS receive premium... (LIS) program.
What Is Insulin?
Insulin is a naturally occurring hormone that your pancreas produces for regulating your blood sugar, also known as glucose, the body’s primary source of energy. Insulin maintains your blood sugar levels by storing away excess blood sugar in the liver and will release the stored glucose to keep things perfectly balanced. However, if you have a condition that interferes with your natural insulin, such as diabetes, then you will need to inject insulin in order to supplement and balance your blood sugar levels.1Mayoclinic.org, “Diabetes treatment: Using insulin to manage blood sugar“, Accessed January 3, 2022
How Does Medicare Cover Insulin?
Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. (Part A and Part B) does not cover prescription medications, including insulin. The only exceptionIn a Medicare Part D plan, an exception is a type of prescription drug coverage determination. You must request an exception, and your doctor must send a supporting statement explaining the medical reason for the... for insulin coverage through Original Medicare is when you require an external insulin pump for your treatment. In order to get coverage for an insulin prescription, you will need a Medicare Part D plan.2Medicare.gov, “Insulin“, Accessed January 3, 2022
Some Medicare Part D plans do not cover insulin at all. Those that do cover it in one of the higher cost tiers, making it expensive. The exact medications a Part D plan covers, and the copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service. or coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. you’ll pay at the pharmacy, are based on the plan’s formularyA formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered..3Medicare.gov, “What Medicare Part D drug plans cover“, Accessed January 3, 2022
Fortunately, CMS is responding to the serious cost impact of insulin and diabetic supplies on Medicare Beneficiaries. Through the Part D Senior Savings Model, Medicare beneficiaries have an increased choice of enhanced Part D plan options that offer lower out-of-pocket costs for insulin. Under this new program, the price of a month-long supply of insulin is capped at $35.6Medicare.gov, “Part D Senior Savings Model“, Accessed January 6, 2022
The Senior Savings Model will continue through December 31, 2025, and contribute to the modernization of Part D benefits. The following pharmaceutical companies are participating in the model:
- Eli Lilly and Company
- MannKind Corporation
- Mylan Specialty L.P., a Viatris Company
- Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
- Sanofi-Aventis U.S. LLC
Medicare Advantage plans are widely embracing the new program. Plans that offer an enhanced Part D plan may participate. The MedicareWire Plan Finder tools for Medicare Advantage and Medicare Part D highlight participating plans.
Low-Income Subsidy – Extra Help
Social Security’s Low-Income Subsidy (LIS) program, also known as Extra Help, can help qualifying Medicare beneficiaries with their remaining costs for their prescription drugs5Medicare.gov, “Find your level of Extra Help (Part D)“, Accessed January 3, 2022. If you qualify for full Extra Help from Social Security, your copayment for insulin is lower than a month’s supply under the Senior Savings Model. If you get partial Extra Help, you pay a small deductibleA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share. (up to $92 per year), after which you pay a 15 percent coinsurance.2Medicare.gov, “Insulin“, Accessed January 3, 2022
While Original Medicare will not normally cover your insulin prescription, a Medicare Part D plan in your area will. And if it is part of Medicare’s Senior Savings Model program (very likely), you will only need to pay $35 for a month supply of insulin.
If you want to find out if your Part D plan is part of Medicare’s Senior Savings Model program, or if you want to check the level of Extra Help you qualify for, you can call a Medicare professional at 1-800-MEDICARE (1-800-633-4227). TTY users can call Medicare at 1-877-486-2048.
- 1Mayoclinic.org, “Diabetes treatment: Using insulin to manage blood sugar“, Accessed January 3, 2022
- 2Medicare.gov, “Insulin“, Accessed January 3, 2022
- 3Medicare.gov, “What Medicare Part D drug plans cover“, Accessed January 3, 2022
- 6Medicare.gov, “Part D Senior Savings Model“, Accessed January 6, 2022
- 5Medicare.gov, “Find your level of Extra Help (Part D)“, Accessed January 3, 2022