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Ask your 2023 Medicare Part D drug plan for reimbursement if you pay more than $35 for a 30-day supply of your covered insulin product.

Category: Diabetes and Diabetic Coverage
Published: Feb, 27 2023 02:02:35

Beginning in 2023, all Medicare drug plans will offer insulin products found on a Medicare Part D plan's formulary at a copay of no more than $35 for a 30-day supply based on the 2022 Inflation Reduction Act (IRA).

The IRA stipulates that Medicare Part D drug plans must offer various types and forms of insulin for a copay of $35 (or less) per month and will keep this low cost-sharing throughout all phases of coverage including: the plan's Initial Deductible, Initial Coverage phase, and the Coverage Gap (or Donut Hole).  If you have high prescription costs and reach the Catastrophic Coverage phase, you still will pay $35 or less for your insulin for the remainder of the year.

However, since the Inflation Reduction Act was passed so late in 2022 – after Medicare Part D plans had already designed and submitted their 2023 plans – insulin coverage in 2023 will be handled slightly differently than Part D insulin coverage in future years.

For example, many 2023 Medicare Part D plans may need time to update their internal systems to accommodate the new insulin law, so Medicare will allow 2023 plans a 3-month grace period to correct their systems and reimburse their plan members for any insulin (or vaccine) overpayment.

As noted by Medicare:
"Section 1860D-2(b)(9) of the Social Security Act (the Act), as added by section 11406 of the IRA, imposes a $35 monthly limit on cost sharing for covered insulin products throughout all phases of the Part D benefit.

Subparagraph (E) of new section 1860D-2(b)(9) provides a three-month period (January 1, 2023 through March 31, 2023) during which a Part D sponsor may retroactively reimburse beneficiaries within 30 days for amounts paid in excess of the $35 cost sharing maximum in the event that the Part D sponsor has not yet adjusted its claims adjudication systems to implement the new insulin benefit at the point of sale. During this time, a beneficiary may pay the higher plan cost sharing at the point of sale, and the plan must refund the difference between that higher amount and $35 to the beneficiary within 30 days."
Or in more user-friendly Medicare terms:
"If you get a Part D-covered insulin product and pay more than $35 for any month’s supply between January 1, 2023 and March 31, 2023, your Part D plan must reimburse you within 30 calendar days for the amount you paid that’s over $35 per month’s supply.
(Part D plans have until March 31, 2023, to update their systems to make sure you’re charged the correct amount.)
If you haven’t received reimbursement within 30 days, contact your plan."

Question:  Does Medicare also provide a 3-month grace period for the overpayment of covered Part D vaccines?

No.  As noted above, the Inflation Reduction Act provides for a 3-month grace period for the overpayment of covered insulin products so 2023 Medicare Part D plans can update the plan's record keeping systems.

However, no similar grace period is provided for no-cost adult vaccines that are recommended by ACIP.  This means that Medicare Part D beneficiaries should be paying a $0 copay for ACIP-recommended vaccines from the beginning of 2023 (including in the deductible phase).

As noted by Medicare :
"[S]ection 1860D-2(b)(8) of the [Social Security Act], as added by section 11401 of the [Inflation Reduction Act], requires the elimination of beneficiary cost sharing for ACIP-recommended adult vaccines administered in accordance with the ACIP recommendation (hereafter referred to as “ACIP-recommended vaccines”) under a Part D plan throughout the entire Part D benefit beginning January 1, 2023. Unlike the insulin benefit, the statute does not incorporate a three-month grace period for plans to implement the changes to this vaccine coverage."

"PDE Reporting Instructions for Implementing the Cost Sharing Maximums Established by the Inflation Reduction Act for Covered Insulin Products and ACIP-Recommended Vaccines for Contract Year 2023",  September 26, 2022
"7 Things to Know about Medicare Insulin Costs", CMS Product No. 12172, January 2023

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