$35 Insulin Medicare

Posted : admin On 1/29/2022

About 30% of 2021 Medicare prescription drug plans offer insulin at a maximum co-pay of $35 or less per month throughout the initial deductible, initial coverage, and the Donut Hole. But the $35 coverage depends on the plan and the specific type of insulin. Starting January 1, 2021, you may be able to get Medicare drug coverage that offers broad access to many types of insulin for no more than $35 for a 30-day supply. You can get this savings on insulin if you join a Medicare drug plan or Medicare Advantage Plan with drug coverage that participates in. That led to a short video that played during a May 26, 2020, briefing by President Donald Trump in the Rose Garden, as part of the announcement of a new $35 insulin copay cap for certain Medicare. The goal with this program is to reduce Medicare Part D out-of-pocket costs through stable, predictable monthly insulin co-pays throughout coverage phases in the standard benefit design. Many Part D plans (including the plans that have preferred access for Omnipod DASH®) are limiting Insulin costs to $35 a. However, the new CMS model does not require all Medicare drug plans to offer this “supplemental coverage” of insulin - and, as noted in more detail below, a Medicare drug plan that includes this fixed $35 (or-less) insulin coverage does not need to offer the coverage for all types or brands of insulin.

Editor’s Note: People who take insulin require consistently affordable and predictable sources of insulin at all times. If you or a loved one are struggling to afford or access insulin, you can build custom plans based on your personal circumstances through our tool, GetInsulin.org.

$35 insulin medicare deductible

On March 11, the Centers for Medicare & Medicaid Services (CMS) launched a new plan for some Medicare Part D participants to pay a maximum $35 copay for their monthly supply of insulin.

The program is called the Part D Senior Savings Model and applies to participating Part D enhanced plans through Medicare. These enhanced plans have slightly higher premiums (an average of $49.32 per month versus $32.09 per month) than the standard Part D plan, but offer broader prescription drug coverage.

Only insulins created by participating manufacturers will be included, but the intent is for all types of insulin to be covered, including long-acting, intermediate-acting, short-acting, and rapid-acting. As of March 11, Lilly has signed on to participate in this program once it launches on January 1, 2021. CMS is currently inviting other manufacturers to apply by March 18, 2020 to be included in the 2021 plan.

A copay cap provides consistent and predictable access to insulin, allowing insulin-dependent people with diabetes the ability to create reliable budgets for their medication needs. This is different from the current model in which Medicare Part D beneficiaries are often faced with fluctuating prescription costs month to month.

CMS reports that those enrolled in a participating plan should save “an average of $446 in annual out-of-pocket costs for insulin.” While the new model applies to a small part of the population, it reduces a significant burden for some of the most vulnerable members of the population: insulin dependent people with diabetes over the age of 65. The plan also creates a model for how copay caps may be done in future.

Insulin rationing due to unpredictable or inaccessible costs is dangerous for everyone with insulin-dependent diabetes, potentially leading to complications such as nerve damage, amputation, diabetic ketoacidosis and even death.

More information on the new Part D Senior Savings Model can be found here.

This content mentions Lilly, an active partner of Beyond Type 1.
News coverage by the Beyond Type 1 team is operated independently from any content partnerships. Beyond Type 1 maintains full editorial control of all content published on our platforms.

WASHINGTON (AP) — Many Medicare recipients could pay less for insulin next year under a deal President Donald Trump announced Tuesday in a pivot to pocketbook issues important in November’s election.

“I hope the seniors are going to remember it,” Trump said at a Rose Garden ceremony, joined by executives from insurance and drug companies, along with seniors and advocates for people with diabetes.

The deal comes as Trump tries to woo older voters critical to his reelection prospects.

Medicare recipients who pick a drug plan offering the new insulin benefit would pay a maximum of $35 a month starting next year, a savings estimated at $446 annually. Fluctuating cost-sharing amounts that are common now would be replaced by a manageable sum.

The insulin benefit will be voluntary, so during open enrollment this fall Medicare enrollees who are interested must make sure to pick an insurance plan that provides it. Most people with Medicare will have access to them.

Administration officials are hoping the announcement will provide a respite from the grim drumbeat of coronavirus pandemic news.

Stable copays for insulin are the result of an agreement shepherded by the administration between insulin manufacturers and major insurers, Medicare chief Seema Verma told The Associated Press. The three major suppliers, Eli Lilly, Novo Nordisk and Sanofi, were all involved.

How to get cheaper insulin on medicare

“It was a delicate negotiation,” Verma said. Drugmakers and insurers have been at odds in recent years, blaming one another for high prices. “I do think this is a big step.”

The cost of insulin is one the biggest worries for consumers generally concerned about high prices for brand name drugs. Millions of people with diabetes use insulin to keep their blood sugars within normal ranges and stave off complications that can include heart disease, blindness, kidney failure and amputations. People with diabetes also suffer worse outcomes from COVID-19.

An AP-NORC poll this month found warning signs for Trump with older voters. Fifty-four percent of adults 60 and older said they disapproved of how Trump is handling his job as president, while 45% approved.

On Tuesday, Trump tried to suggest former President Barack Obama was responsible for high drug prices. And he took a dig at former Vice President Joe Biden, who’s running to deny him a second term. “Sleepy Joe can’t do this,” Trump said.

The president last week told Republican senators at a Capitol Hill meeting he still wants to pass a bill this year to lower drug costs, saying “I think you have to do it,” according to a summary from an attendee. Bipartisan legislation to limit price increases and reduce costs for older people with high drug bills is pending in the Senate.

But the fate of any drug pricing bill seems to rest with House Speaker Nancy Pelosi, who has a much more ambitious plan for Medicare to negotiate prices for the costliest drugs, not just insulin. Pelosi would use expected savings to provide vision, dental and hearing coverage for older adults. Most Republicans oppose that approach as an expansion of government price-setting.

Although the White House and Pelosi’s office were in conversations last year about action on drug prices, the relationship between the two leaders has been tense and angry for months.


White House Counselor Kellyanne Conway told AP the administration can’t wait for the Democratic-controlled House on drug prices. “Waiting for them to act is very perilous,” Conway said.

Verma, head of the Centers for Medicare and Medicaid Services, said 1,750 insurance plans that offer drug coverage to Medicare recipients have agreed to provide insulin for a maximum copay of $35 a month next year. It will be available through “enhanced” plans that may cost more per month but offer additional benefits such as reduced cost-sharing on certain drugs. The cap on copays is expected to lead to a small increase in premiums.

$35 insulin medicare part

Medicare Insulin 2021

Importantly for patients, the new benefit would cover a range of insulin products, including pen and vial forms for rapid-acting, short-acting, intermediate-acting and long-acting versions.

One out of three people with Medicare have diabetes, and more than 3 million use insulin. At list prices, the drug can cost more than $5,000 a year. Although insured patients don’t pay that, they do notice rising copays that are based on the full cost. People who can’t afford their insulin may try to cope by reducing their doses, a dangerous calculation that can put their lives in jeopardy.

$35 Insulin Medicare Part

Medicare’s prescription drug benefit is offered by private insurers, either as a stand-alone “Part D” drug plan added to traditional Medicare, or as part of a managed care plan under Medicare Advantage. The taxpayer-subsidized private plans are closely regulated by the government, but by law Medicare is barred from negotiating drug prices — something Democrats including Biden want to change.

Humana Insulin Savings Program


Insurers and drugmakers welcomed the announcement. The industry group America’s Health Insurance Plans called it an “excellent example of public-private partnerships where everyone wins.” The Pharmaceutical Research and Manufacturers of America said it’s pleased to see the administration focused on lowering out-of-pocket costs for patients.

$35 Insulin Medicare Deductible

Medicare estimates that about 6 in 10 beneficiaries are already in prescription drug plans that will offer the new insulin benefit. Those whose plans don’t offer the new option can switch during open enrollment season, which starts Oct. 15. Medicare’s online plan finder will help beneficiaries find plans that cap insulin copays.

The insulin benefit will be available in all 50 states, Washington, D.C., and Puerto Rico. Participation is voluntary for insurers and Medicare recipients alike.


Associated Press writer Hannah Fingerhut contributed to this report.