A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu
  • Home
  • Contact
  • MAPD
  • PDP
  • 2023
  • FAQs
  • Articles
  • Search
  • Contact
  • 2023
  • FAQs
  • Articles
  • Latest Medicare News
  • Search

Will all 2023 Medicare drug plans cover formulary insulin for only $35 per month (or less)?

Category: Insulin and Diabetic Supplies
Updated: Jul, 09 2023

Yes.  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 30-day 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 never exceeding the $35 co-pay.  (The IRA will eliminate beneficiary cost-sharing during the Catastrophic Coverage phase in 2024.)

However, unlike the existing Senior Saving Model, the new Inflation Reduction Act will expand the insulin $35 co-pay to all Medicare Part D prescription drug plans or Medicare Advantage plans offering prescription drug coverage (MAPDs) for all Part D forms of insulin found on a plan's formulary or drug list.

And beginning July 1, 2023, insulin furnished through Medicare Part B durable medical equipment (DME) will also have a monthly co-pay of no more than $35.

Finally, starting in 2026, the United States government can begin negotiating drug prices directly with pharmaceutical companies, so the future co-pay for insulin may be less than $35 depending on the government's negotiated price.

Question:  Can a 2023 Medicare drug plan implement both the Inflation Reduction Act for $35 insulin and the Senior Savings Model for select low-cost insulin?

Yes.  In 2023, your Medicare drug plan can have two different insulin savings programs - with covered insulin products never costing more than $30 for a 30-day supply.

First, as noted above, all 2023 stand-alone Medicare Part D prescription drug plans (PDPs) and Medicare Advantage plans with drug coverage (MAPDs) will offer all insulin products found on the plan’s formulary for a co-pay of $35 (or less) through all phases of Part D coverage (with insulin costs possibility reduced further in the Catastrophic Coverage phase).

In addition, about 30% of 2023 Medicare drug plans will also implement the Senior Savings Model, offering various “select” types of insulin for a $35 or less co-pay – and all other formulary insulin will still be $35 or less.

How can a Medicare drug plan offer two $35 or less co-pay insulin programs at the same time?

As an example, you may find that your Medicare drug plan may offer some "select" insulin (as noted on the formulary) for a copay of $11 at preferred pharmacies and $33 at regular network pharmacies.  These select insulin products may be listed as Tier 3 drugs.

At the same time, the same Medicare drug plan will offer all additional insulin products featured on the drug plan’s formulary with a co-pay of $35.  So all insulin products (other than the "select" insulins) will be listed as Tier 6 drugs.

Sources include:


Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs

Browse FAQ Categories

Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.