Insulin Users May Benefit From Medicare Senior Savings Model

Seniors with diabetes may pay less for insulin with this program, which debuts in some Medicare drug plans in 2021.

If you use insulin and you’re eligible for Medicare Part D prescription drug coverage, a new government program may help you save a lot of money on your medicine next year.

Under the Part D Senior Savings Model, Medicare recipients in participating plans will pay no more than a $35 copay for a month’s supply of insulin. This change is made to reduce the impact of insulin prices on seniors living with diabetes and the burden it has caused. According to the Kaiser Family Foundation analysis, people with Medicare Part D spent $984 million in 2017 out-of-pocket on insulin products. This is nearly four times the amount they paid ten years ago.

The foundation reports that diabetes is more common in people aged 65 and over. More than a third of Medicare beneficiaries have diabetes. CMS estimates that the Senior Savings Model could help people with diabetes save an average of $446 per year, or 66% in insulin costs.

CMS reports that more than 1,750 Medicare Part D prescription drugs plans and Medicare Advantage plans with prescription drug coverage in all 50 States applied for the new program during the open enrollment period of 2021, which runs through December 7. It’s worth checking to determine if the new price will be offered by a plan within your area.

While the savings on insulin are welcome, there are many caveats to the rollout. Different insurance companies classify the program differently, so it is difficult to determine if the plan you have or the one you are looking at offers the lowest prices. Even if you do find a participating plan that covers insulin, it might not cover the type you currently prescribe.

It’s wonderful to have affordable insulin, according to Sue A. Greeno (Center for Medicare Advocacy), a Medicare advocate. However, there is still a lot to be confused about choosing prescription drug coverage.

These are the essential facts for diabetes patients to be able to get the most out of their Medicare Part D prescription drug coverage.

How Medicare Part D works

You can purchase Medicare Part D prescription drug coverage in two ways — through a stand-alone Medicare Part D plan or via a Medicare Advantage Plan that includes Part D prescription drug coverage. Private insurers sell both types of plans.

All plans must provide the same level of coverage as Medicare. They must all cover the same types of drugs as Medicare, including diabetes medications. However, plans can select which drugs they will cover in each category. They must cover at least two of the most prescribed drugs.

Medicare Part D plans must cover insulin injections and inhaled insulins for diabetes drugs. Medicare Part B may cover insulin pumps, as well as insulin externally. Only enhanced Medicare Part D plans are eligible for the Senior Savings Model. These plans often have slightly higher premiums, but provide greater coverage for a wider range of medicines.

How much insulin you will pay with Senior Savings

The new program changes the complicated formula used to determine what insurers and manufacturers can charge for insulin products in a way that reduces the patients’ costs. The new program also eliminates the need for insulin copays, which are not subject to deductibles, or what is known as the coverage gap.

When you and your insurer have spent $4,130 on prescription drugs for plan year 2021, the coverage gap begins. After that, you are responsible for 25% of all of your medicine costs. Participants in participating plans pay the monthly copay of $35 for insulin.

After Medicare beneficiaries have spent $6,550 in 2021 out-of-pocket for prescription drugs (not including the insurer’s share), they will be eligible for Part D’s catastrophic coverage phase. This phase will see out-of-pocket drug expenses dramatically reduced. People with diabetes will be responsible for 5% of insulin costs regardless of whether they are enrolled in a Senior Savings Model plan.

How to compare plans

You can look for Medicare Part D and Medicare Advantage plans that are participating in the new program on’s plan finder. This tool will allow you to search for Medicare Part D and Medicare Advantage Plans with Part D coverage in your area. You can also enter the list medicines that you use, including insulin, when you use the tool. You can also filter plans that are part the Senior Savings Model. Click on “Filter Plans” to check the box for insulin savings.

These are still early days, and the insurers are testing the program by limiting rollouts. Aetna is, for instance, focusing on Florida. Christopher Ciano, president and CEO of Aetna Medicare says that Aetna only participates in a few geographic areas initially. “We want to find out if the program is sustainable over time that will lead to savings.

Participating plans may be found if you look closely at the details. This will ensure that the insulin you are taking is included on the list of drugs covered under the insurance. This is also known as a formulary. This will allow you to compare prices from up to five pharmacies within your local area. There may be a range of copays between pharmacies. Some charge the full $35 for a monthly insulin dose, while others charge less.

Compare all plans you see in your search, even those not participating in the insulin savings program. You may find that a plan that has low deductibles or low copays for all your medications, depending on the price of the insulin you use, is more affordable than one that participates in the Senior Savings Model.

For help finding Medicare coverage, contact your local State Health Assistance Program or your local senior center for help.