First available in 2021, the Medicare Part D "Senior Savings Model" (SSM), is a voluntary program where stand-alone Medicare Part D plans (PDPs) and Medicare Advantage plans
with drug coverage (MAPDs) could offer coverage of certain types of
insulin at a co-pay of $35 (or less) per month throughout most phases of
your drug coverage including your plan's: initial deductible, initial
coverage phase, and the Coverage Gap (or Donut Hole
However, the Senior Savings Model does not apply to the Catastrophic Coverage phase
(where you will pay a maximum of 5% of the retail drug cost for formulary insulin).
The Centers for Medicare and Medicaid Services (CMS) introduced the Senior Savings Model on May 11, 2020 and then announced more about the possibility of 2021 Medicare plans offering low-copay insulin in a July 29, 2020 Press Release noting:
“Earlier this year, [Medicare] launched the Part D Senior Savings Model, which will allow Medicare beneficiaries to choose a [Medicare drug] plan that provides access to a broad set of insulins at a maximum $35 copay for a month’s supply. Starting January 1, 2021, beneficiaries who select these plans will save, on average, $446 per year, or 66 percent, on their out-of-pocket costs for insulin.”
The Senior Savings Model was popular from the start with over 30% of all stand-alone Medicare Part D plans (PDPs) and Medicare Advantage plans with drug coverage (MAPDs) offering the low-cost coverage of certain insulin products and a CMS Press Release on September 24, 2020
announced that "seniors [across the country] who use insulin will have
over 1,600  Medicare Advantage and Part D prescription drug plans
to choose from that will offer insulin at no more than a $35 monthly
As a more recent example, in 2022 Arizona
residents had the option of ten (10) stand-alone 2022 Medicare Part D prescription drug plans offering $35 or less insulin.
As another example, Medicare beneficiaries in Florida will have the choice of 22 stand-alone 2022 Medicare Part D plans
and eight (8) of these plans will offer insulin for a $35 or-less
co-pay (most other states offered a selection of seven or eight drug plans participating in the Senior Savings Model).
As a county-wide example, in 2022, residents of St. Johns County, Florida hadaccess to
13 Medicare Advantage plans
(MAPD) and one chronic-illness Medicare Advantage Special Needs Plan (c-SNP) offering the low-co-pay insulins.
The coverage of $35 (or less) insulin can be provided by:
(1) stand-alone Medicare Part D plans (PDPs) with enhanced alternative features,
(2) Medicare Advantage plans that include drug coverage (MAPDs), and
(3) Chronic Illness or Institutional Special Needs Plans (SNPs).
Before the 2023 plan year (see below), Medicare Part D plans or Medicare
Advantage plans offering the $35 or less insulin were show with the
text “insulin coverage $35 or less
” in our Medicare Part D Plan Finder (PDP-Finder.com
) and Medicare Advantage Plan Finder (MA-Finder.com
). Below is a 2021 Florida
example of our PDP Finder
highlighting a plan offering low-copay insulin.
Note: The Senior Savings Model coverage is only for non-LIS beneficiaries
- The $35 (or less) insulin Senior Savings Model coverage is not
available to Medicare beneficiaries who qualify for the Medicare Part D
Extra Help program or Low-Income Subsidy (LIS
) - since people qualifying for LIS already receive low-cost insulin coverage.
Note: The Senior Savings Model does not apply to all Medicare Part D and Medicare Advantage plans.
The CMS Senior Saving model did not require all Medicare drug plans
this “supplemental coverage” of insulin --- and 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 found on the
The following pharmaceutical manufacturers are participating in the Part D Senior Savings Model for CY 2023:
Important changes to insulin coverage starting January 1, 2023: All Medicare drug plans - all formulary insulins - all $35 or less per month.
- Eli Lilly and Company
- Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
- Sanofi-Aventis U.S. LLC
- MannKind Corporation
- Mylan Specialty L.P.
In 2023, the Inflation Reduction Act (IRA) of 2022
introduces a provision similar to the 2021-2022 Senior Savings Model
with insulin provided at a $35 co-pay throughout all phases of your
Medicare Part D plan coverage (up to the 2023 Catastrophic Coverage
phase where you will pay only 5% of the retail price - the IRA will eliminate the Catastrophic
Coverage phase in 2024).
However, unlike the
Senior Saving Model, the new Inflation Reduction Act will expand the
insulin $35 co-pay to all
Medicare Part D plans and Medicare Advantage plans offering drug coverage and all
Part D forms of
insulin covered by the plan. That is, all insulin found on the plan's formulary will have a co-pay of $35 or less.
Then, beginning July 1, 2023
furnished through Medicare Part B durable medical equipment (DME) will
also have a monthly co-pay of no more than $35.
Next, starting in 2026,
the government can begin negotiating drug prices, so the co-pay for
insulin may be less than $35 depending on the negotiated price reached by the government.
https://www.cms.gov/newsroom/press-releases/cms-launches-groundbreaking-model-lower-out-pocket-expenses-insulin (May 11, 2020)
(July 29, 2020)