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How will I know if my Medicare Part D drug plan covers insulin for $35 or less?


To learn more about low-cost insulin coverage, you can:
  • 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.

Question:  What is the Senior Savings Model?

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.

Example of Formulary covering insulin under SSM

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".

 

Example of Medicare.gov insulin under SSM
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.

Remember, 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.
  As noted above, Medicare Part D plans or Medicare Advantage plans offering the $35 or less insulin 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).
 
Example of Q1Medicare Plan Finder showing plan covering insulin under SSM

You can then click on the plan's name for more coverage information and the toll-free number to call the plan's Member Services Department for more details about the insulin coverage (cost at a preferred and standard network pharmacy and the specific types of insulin covered under the Senior Savings Model).







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Tips & Disclaimers
  • 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 PDP-Compare.com and MA-Compare.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.
  • 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.