Archive: What is the insulin Senior Savings Model?

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 [2021] Medicare Advantage and Part D prescription drug plans to choose from that will offer insulin at no more than a $35 monthly copay".

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.

Q1Medicare Medicare Part D Plan Finder Senior Saving Model

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 to offer 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 plan's formulary.

The following pharmaceutical manufacturers are participating in the Part D Senior Savings Model for CY 2023:

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

Important changes to insulin coverage starting January 1, 2023: All Medicare drug plans - all formulary insulins - all $35 or less per month.

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, insulin 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. References:

https://www.cms.gov/newsroom/press-releases/cms-launches-groundbreaking-model-lower-out-pocket-expenses-insulin (May 11, 2020)
https://www.cms.gov/newsroom/press-releases/trump-administration-continues-keep-out-pocket-drug-costs-low-seniors (July 29, 2020)
https://innovation.cms.gov/innovation-models/part-d-savings-model