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About Medicare
Jun 26, 2024

Understanding Insulin Coverage Under Medicare

insulin; medicare coverage
The Senior Savings Model for insulin is a Medicare initiative designed to make insulin more affordable for Medicare beneficiaries. Here’s what you need to know about how Medicare handles insulin coverage, and some tips on how to manage these expenses effectively.

Overview of the Senior Savings Model

This program was introduced to address the high cost of insulin, which is a vital medication for many people with diabetes. Under the model, participating Medicare drug plans cap the out-of-pocket cost of insulin at $35 per month for a 30-day supply. This fixed price is significantly lower than what many beneficiaries were paying prior to the introduction of the model.

Key Features of the Senior Savings Model

  1. $35 Cap on Insulin Costs: The cap applies regardless of the phase the beneficiary is in, including during the deductible, initial coverage, and the coverage gap (often called the “donut hole”).
  2. Applies to Multiple Types of Insulin: The model covers most types of insulin, including rapid-acting, long-acting, and premixed formulations. However, beneficiaries should check with their plan to see exactly which types of insulin are covered under the $35 cap.
  3. Year-Round Savings: The cost cap is maintained throughout the year, preventing fluctuations in insulin costs, which can be particularly beneficial for budgeting and financial planning.
  4. Participation by Medicare Drug Plans: Not all Medicare Part D and Medicare Advantage plans participate in the Senior Savings Model. Beneficiaries must enroll in a participating plan to benefit from the capped insulin prices.

Ways to get Insulin Coverage

  1. Medicare Part D: Insulin is generally covered under Medicare Part D, which is the prescription drug plan. To access this benefit, beneficiaries need to be enrolled in either a standalone Part D plan or a Medicare Advantage plan that includes drug coverage. It’s important to review each plan’s formulary to confirm that your specific type of insulin is covered.
  2. Medicare Advantage Plans (Part C): Some Medicare Advantage plans offer enhanced prescription drug coverage that may include insulin. These plans often have different cost structures and may provide more comprehensive coverage than standard Part D plans.

Expected Costs for Insulin Under Medicare

The costs for insulin under Medicare can vary based on several factors, including the chosen Medicare plan, the type of insulin, and whether the pharmacy is in the plan’s network. Here’s what beneficiaries might expect:
  • Deductibles: The Part D deductible varies by plan. Some plans may not apply the deductible to insulin, especially if enrolled in a plan participating in the Senior Savings Model.
  • Copayments and Coinsurance: These are determined by the plan’s structure. With the Senior Savings Model, the copayment for insulin is capped at $35 per month.
  • Coverage Gap (“Donut Hole”): Beneficiaries enter this phase after their plan has spent a certain amount on covered drugs. Under the Senior Savings Model, insulin costs remain at $35 per month even during the coverage gap phase.

Tips for Lowering Insulin Costs

  1. Enroll in a Part D Plan Participating in the Senior Savings Model: This can significantly reduce monthly insulin costs.
  2. Review and Compare Plans Annually: During the Annual Enrollment Period (AEP), compare different Medicare plans to see which offers the best coverage for your insulin needs at the lowest cost.
  3. Utilize Extra Help: Low-income beneficiaries may qualify for Extra Help from Medicare to pay for prescription drugs, which can further reduce the cost of insulin.
  4. Manufacturer Assistance Programs: Some insulin manufacturers offer assistance programs that can help reduce the cost of insulin for those who qualify.
  5. State Pharmaceutical Assistance Programs: Some states offer programs to help pay drug plan premiums and other drug costs.
Understanding and navigating Medicare’s coverage options for insulin can be complex, but with the right information and planning, it is possible to manage these costs effectively. AMAC’s team of Medicare Advisors is here to help you choose the best plan for your health needs! For help with Medicare plans – or any questions you may have about Medicare – contact AMAC’s Medicare Advisory Service at 1-855-611-4856 or request a quote below!  
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