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If You’re A Diabetic Medicare Beneficiary, Here’s What You Should Know About $35 Insulin

Diane Omdahl | Forbes | 10/20/2020

You’ve seen the headlines.

CMS Launches Groundbreaking Model to Lower Out of Pocket Expenses for Insulin

Most Medicare Enrollees Could Get Insulin For $35 A Month

New CMS Model will Reduce Out-of-Pocket Costs for Insulin to $35 for Medicare Part D Beneficiaries

On March 11, the Centers for Medicare and Medicaid Services (CMS) announced the Part D Senior Savings Model. Plans that provide Part D prescription drug coverage can choose to offer insulin for a maximum copayment of no more than $35. 

In 2020, a monthly copayment for insulin can range from $2 to $200 or more, depending on the medication, plan and place of residence. According to the CMS announcement, the Senior Savings Model could save beneficiaries who take insulin about $466 a year. 

The opportunity to get insulin for $35 a month is a very good deal. However, this isn’t automatic and some diabetic beneficiaries may be left out in the cold. I reviewed plans in one ZIP code in Los Angeles, Milwaukee and New York City. This review was just a spot check, not an exhaustive analysis. But it gives us a glimpse of how the plans work and fine points beneficiaries must check.

Here are some important points about the Senior Savings Model.

This program applies only to insulin.

You won’t find $35 prices on oral medications to control Type 2 diabetes or non-insulin injectable medications.

The $35 copayment would start from the first dose.

There would be no deductible and the copayment would apply through " href="" target="_self" data-ga-track="">the Coverage Gap (donut hole) to the last payment stage, Catastrophic Coverage. Once in that last stage, the beneficiary would pay no more than 5% of the full price. 

The reduced copayment applies no matter how you get your medications, as long as you stay in-network.

You would pay no more than $35 at an in-network preferred or standard retail pharmacy or with mail-order service.  

The program is voluntary.

Sponsors of standalone Part D and Medicare Advantage plans can choose whether or not to participate. 

According to the Medicare Plan Finder, 11 of 59 Medicare Advantage plans in one Los Angeles ZIP code participate and, in New York City, nine of 50 plans. These are a mix of HMO (health maintenance organization), HMO-POS (HMO with a point of service option) and PPO (preferred provider organization) plans. There are also some Special Needs Plans (SNP) in the program but the Plan Finder does not include that type of plan. (SNPs limit membership to those with specific diseases.)

There are five companies sponsoring standalone Part D drug plans in all counties across the country. You may find other companies, depending on where you live.

However, not every drug plan offered by the participating companies is in the Senior Savings Model.

In a Milwaukee ZIP code, one company has three plans with monthly premiums of $32, $40 and $92 but only the one with the highest premium is participating. Then, a second company has one plan with a $24 premium participating but not the plan with an $87 premium. 

Not every plan in the model covers every insulin.

I entered nine different insulins, a mix of rapid, intermediate, long-acting and pre-mixed, into the Medicare Plan Finder. Of the participating standalone plans, the number of insulins covered ranged from four to six, with each plan covering a different assortment. Interestingly, I found one Medicare Advantage plan in Wisconsin not in the program that covers all nine insulins. 

If you take insulin, consider these actions. 

  • Review your " href="" target="_self" data-ga-track="">. If your plan offers payments of no more than $35, you should find that in the section on changes to prescription drug costs. 
  • Check other plans in your area to find those that participate. Log into your account and access the Medicare Plan Finder. In the upper right-hand corner of any page, click on “Show me 2021 plans.” Then, on the “Plans Available” screen, click on “Filter Plans” and “Insulin savings.” Participating plans will appear in order of lowest “estimated total drug + premium cost.”
  • Pay attention to the cost for all your medications. It’s possible that a plan with less-expensive insulin may not be the best, depending on other drugs you take. 
  • Realize that you may not end up with a $35 copayment in 2021. However, this is a brand new program and, if successful, it will likely expand in years to come.

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