To learn more about low-cost insulin coverage, you can:
Question: What is the Senior Savings Model?
- Contact the Medicare drug plan's Member Services Department,
- Review the drug plan's Evidence of Coverage document,
- Speak with a Medicare representative (1-800-633-4227),
- Check the Medicare.gov Plan Finder, or
- See our Medicare Plan Finders (https://PDP-Finder.com or https://MA-Finder.com) for the text “insulin coverage $35 or less” show with Medicare drug plans offering low-cost insulin.
The new Centers for Medicare and Medicaid Services (CMS) Part D Senior Savings Model
encourages Medicare drug plans to offer low-cost and Medicare Advantage plans.
And starting in 2021, about 30% of all stand-alone Medicare Part D plans (PDPs) and Medicare Advantage plans with drug coverage (MAPDs) will offer different types of insulin for a maximum co-pay of $35 per month throughout the plan's: initial deductible, initial coverage phase, and the Coverage Gap (Donut
Hole). In the Catastrophic Coverage phase
(after the Coverage Gap), the plan beneficiary would pay 5% of the retail drug cost for insulin.
Question: What can you expect when reviewing the Medicare plan's Evidence of Coverage or other plan documents?
A Medicare Part D plan's website will probably be the first place that you can read more about the plan's participation into the Senior Savings Model. For example, if you are on the WellCare.com/PDP
site, you can enter a Zip and choose your type of Medicare plan, then if you review the webpage for the 2021 WellCare Wellness Medicare Part D plan, you will find text such as:
"Senior Savings Model - If you are not receiving Extra Help to pay for your prescriptions, the amount you pay when you fill a prescription for select insulins will be a reduced, fixed amount during the deductible, initial coverage, and coverage gap phases of the Part D benefit. Please refer to your Evidence of Coverage for more information about this coverage."
The WellCare Wellness Rx (PDP) Evidence of Coverage then notes:
"WellCare Wellness Rx (PDP) offers additional gap coverage for select insulins. During the Coverage Gap stage, your out-of-pocket costs for select insulins will be $35. Please go to Chapter 4, Section 2.1 [of the EOC document] for more information about your coverage during the Coverage Gap stage. Note: This cost-sharing only applies to beneficiaries who do not qualify for a program that helps pay for your drugs (“Extra Help”). To find out which drugs are select insulins, review the most recent Drug List [formulary] we provided electronically. If you have questions about the Drug List, you can also call Member Services (Phone numbers for Member Services are printed on the back cover of this [EOC] booklet) [or 1-888-550-5252 (TTY/TDD users should call 711]."
The WellCare Wellness EOC document also show the cost of various form of insulin as: "$35 for standard and preferred cost-sharing, Out of network (in certain situations) $35".
The Evidence of Coverage then continues on to address the supplemental Donut Hole or Gap coverage that is provided to certain types of insulin:
"WellCare Wellness Rx (PDP) offers additional gap coverage for select insulins. During the Coverage Gap stage, your out-of-pocket costs for select insulins will be$35."
Lastly, you will notice the "SSM" notation in the Medicare Part D plan's formulary or drug list showing the types of insulin that are subject to the $35 coverage through the Senior Savings Model. In this example of the WellCare Wellness Rx formulary, you can see the types of insulin receiving the coverage.
Please see our article "Which insulin will be covered for only $35 or less per month?
" showing the different types and forms of insulin along with their National Drug Codes
Question: How do you see Medicare drug plans covering insulin for $35 or less on the Medicare.gov Plan Finder?
Use the Medicare.gov Plan Finder "Filter".
When using the Medicare.gov Plan Finder (found at: https://www.medicare.gov/plan-compare), enter your chosen plan criteria (Zip, Medicaid status, drugs, pharmacy), then once you move to the screen showing all Medicare plan's meeting your criteria, you can use the additional filter option (Filter Plans
) found at the top of the page and select to see the Medicare plans that provide "Insulin savings".
You will see that the number of Medicare drug plans is reduced down by about 30% (as in this example) and then you can review each plan's coverage details to learn more about the coverage cost at your chosen pharmacies.
, not all types of insulin are covered
by a Medicare drug plan under the Senior Savings Model so be sure to confirm how your exact insulin is covered.
Question: How do you find Medicare drug plans covering insulin for $35 or less on the Q1Medicare site?
See our Q1Medicare Medicare Plan Finders and use our search filter "Insulin $35 or less plans".
Medicare Part D plans or Medicare Advantage plans offering the $35 or less insulin will show the text "select insulin pay $35 copay
" (or $25 or $11 co-pay, depending on the plan) or if we do not know the co-pay, we will show the dark green text: "insulin coverage $35 or less
" in our Medicare Part D Plan Finder (https://PDP-Finder.com
) and Medicare Advantage Plan Finder (https://MA-Finder.com
You can then click on the Medicare plan's name (for example, WellCare Wellness Rx) to review more coverage information and find the toll-free number to call the plan's Member Services Department to learn more about the plan's insulin coverage (cost at a preferred and standard network pharmacy and the specific types of insulin covered under the Senior Savings Model).