All Insulin products covered by your Medicare Part D drug plan will cost $35 or less for a 30-day supply.

In 2023, the Inflation Reduction Act (IRA) introduces an insulin cost-saving provision - similar to the existing Senior Savings Model (SSM) - with coverage for all formulary insulin at a $35 (or less) monthly copay throughout all phases of Medicare Part D plan coverage (up to the 2023 Catastrophic Coverage phase where you will pay only 5% of the retail price not to exceed $35).

Blending the 2023 Senior Savings Model into the 2023 Inflation Reduction Act.

So yes, in 2023, there are two similar programs that are both focused on providing low-cost insulin products to members of Medicare Part D drug plans or Medicare Advantage plans with drug coverage (MAPDs) and here is how you may find the two programs working together.

Since the Inflation Reduction Act was passed in mid-2022 - and about 30% of Medicare drug plans had already submitted 2023 drug plan designs that included the now somewhat-redundant Senior Savings Model (allowing for $35 or less copays for some "select insulin products) -  it is possible that a 2023 Medicare Part D or Medicare Advantage plan may offer certain insulin products at a $35 or lower co-pay - and at the same time, must offer all formulary insulin products at a maximum $35 copay.

(1) Question:  Can my 2023 Medicare Part D plan have different cost sharing for different insulin without exceeding $35 a month?

Yes.  It is possible that your 2023 Medicare Part D plan may offer two different programs that both provide insulin for $35 or less.  For example, you may find that your plan offers “select insulins” for $11 or $33 (depending on whether preferred or standard network pharmacy) – and all other formulary insulin products for the mandatory $35 (or less) co-pay.

(2) Question:  So will my plan have different formulary tiers for SSM insulin and IRA insulin?

Yes.  For example, your Medicare drug plan may organize the Senior Savings Model "select insulins" on a Tier 3 (because the Senior Savings Model applied to only certain insulin products) - and then, to accommodate the Inflation Reduction Act - your drug plan will organize all other insulin products on Tier 6 (since all insulins must have a cost-sharing of $35 or less per month).

In such a case, the formulary Tier level for your insulin is almost irrelevant to what you pay (and the tier-level only helps your plan organize the drugs) – in the end, no matter what the tier, you pay no more than $35 for the 30-day supply.

(3) Identifying lower-costing SSM "select insulin" on a formulary

You will need to look within your plan's documentation (Evidence of Coverage) or printed formulary or online to learn more about how different insulin products are covered by your Medicare drug plan.

As part of the CMS 2023 "Part D Senior Savings Model" (SSM or Model), about 30% of all stand-alone Medicare Part D plans (PDPs) and Medicare Advantage plans with drug coverage (MAPDs) will offer coverage of different types of insulin at a maximum co-pay of $35 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).

The Senior Savings Model does not apply to your Catastrophic Coverage phase (where you will pay 5% of the retail drug cost).  However, since the IRA extends over the SSM, Catastrophic Coverage of SSM "select insulin" will still not exceed $35.

Please see the table below showing some of the different types and forms of  "select" insulin covered by the Senior Savings Model (SSM) along with the National Drug Codes identifying the insulin products.

You can use our Formulary Browser, Q1Rx Drug finder or contact the Medicare drug plan for details about which specific types of insulin will be covered on their plan and at which cost-sharing.

(Note to 2023 Medicare drug plans - since the IRA was passed so late in the 2022 Medicare Part D drug plan "year", many 2023 drug plans still have not updated the cost-sharing for insulins or "select insulins" and some 2023 cost or pricing data may be lacking even at the January 1, 2023 start of the plan year.)

• Eli Lilly and Company
• Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
• Sanofi-Aventis U.S. LLC
• MannKind Corporation
• Mylan Specialty L.P.

Sources include: