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) introduced an insulin cost-saving provision - similar to the old 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 Catastrophic Coverage phase where all Medicare beneficiaries now have a $0 copay for a formulary medications).


And a bit of history...

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

In 2023, there were two similar programs that were 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 offered certain insulin products at a $35 or lower copay - and at the same time, were required to offer all formulary insulin products at a maximum $35 copay.

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

Yes.  It was possible that your 2023 Medicare Part D plan offered two different programs that both provided insulin for $35 or less.  For example, you may found that your plan offered “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) copay.

(2) Question:  So did my 2023 Medicare Part D plan have different formulary tiers for SSM insulin and IRA insulin?

Yes.  For example, your Medicare drug plan may have organized 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 organized 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 was almost irrelevant to what you paid (and the tier-level only helped your plan organize the drugs) – in the end, no matter what the tier, you paid no more than $35 for the 30-day supply.

(3) Identifying lower-costing SSM "select insulin" on a 2023 formulary

Your plan's 2023 documentation (Evidence of Coverage) or printed formulary or online formulary offered information about how different insulin products were covered by your 2023 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) offered coverage of different types of insulin at a maximum copay of $35 per month throughout most phases of drug coverage including your plan's: initial deductible, initial coverage phase, and the Coverage Gap (or Donut Hole).

The Senior Savings Model did not apply to your 2023 Catastrophic Coverage phase (where you paid 5% of the retail drug cost).  However, since the IRA extended over the SSM, 2023 Catastrophic Coverage of SSM "select insulin" did not exceed $35.

Please see the table below showing some of the different types and forms of  "select" insulin covered by the 2023 Senior Savings Model (SSM) along with the National Drug Codes identifying the insulin products.

You can use our 2023 Formulary Browser, 2023 Q1Rx Drug finder or contact the Medicare drug plan for details about which specific types of insulin were 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 did not update the cost-sharing for insulins or "select insulins" and some 2023 cost or pricing data was lacking during the entire 2023 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.

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