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Will some 2021 Medicare drug plans cover insulin for only $35 per month?


Yes.  As part of the new CMS "Part D Senior Savings Model" (Model), about 30% of all 2021 stand-alone Medicare Part D plans (PDPs) and Medicare Advantage plans with drug coverage (MAPDs) will offer coverage of different types of insulin at a maximum co-pay of $35 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) - - - but, the Senior Savings Model does not apply to your Catastrophic Coverage phase (where you will pay 5% of the retail drug cost).

For example, ten (10) stand-alone 2021 Medicare Part D prescription drug plans in Alabama, Florida, Pennsylvania, Tennessee, and West Virginia will offer the Senior Savings Model and all other states across the country will offer nine (9) stand-alone Medicare Part D plans with the low-copay insulin.

The Centers for Medicare and Medicaid Services (CMS) introduced the Senior Savings Model in early 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.”
As noted, 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).

Medicare Part D plans or Medicare Advantage plans offering the $35 or less insulin will show the 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).
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.

Question:  Will all Medicare Part D and Medicare Advantage plans offer insulin for $35 or less?

No.  The new CMS model does not require all Medicare drug plans to offer this “supplemental coverage” of insulin --- and, as noted in more detail below, 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.

However, a large number of 2021 Medicare Advantage plans and Medicare Part D plans in every state should offer the low-copay insulin.  In fact, the 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 mentioned, we found 31% of all stand-alone Medicare Part D plans and 29% of Medicare Advantage plans with drug coverage offered the low-copay insulin.)

The following pharmaceutical manufacturers are participating in the Part D Senior Savings Model for CY 2021:
  • Eli Lilly and Company
  • Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
  • Sanofi-Aventis U.S. LLC
As an example, Medicare beneficiaries in Florida will have the choice of  28 stand-alone 2021 Medicare Part D plans and 10 of these plans will offer insulin for a $35 or-less co-pay.  And residents of St. Johns County, Florida will have access to 7 Medicare Advantage plans (MAPD) and one chronic-illness Medicare Advantage Special Needs Plan (c-SNP) offering the low-co-pay insulins.

Question:  How do I know which Medicare drug plans will offer the $35 insulin?

There are several ways to determine whether a Medicare Part D or Medicare Advantage plan will offer insulin at a $35 or less co-payment.

1.  Contact the Medicare drug plan's Member Services Department.

2. Review the Medicare plan's Evidence of Coverage document or Formulary.

For example, you can review the WellCare Wellness Rx Medicare Part D plan's formulary (see the WellCare Wellness formulary graphic further down the page) and you find the plan uses "SSM" in the formulary to indicate $35 insulin - with the formulary key stating:

"SSM stands for 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."

(https://wellcare.com, https://fm. formularynavigator.com /FBO/67/06_GS_Core_ Enh_PDP_CompForm_21383.pdf)

3.  Use the Medicare.gov Plan Finder Senior Savings Model "Filter".
When using the Medicare.gov Plan Finder, you can use the additional filter option (Filter Plans) found at the top of the results page and select to see the Medicare plans that provide "Insulin savings".

4.  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 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).

For more information and examples, please see our Frequently Asked Question "How will I know if my Medicare Part D drug plan covers insulin for $35 or less?"

Question:  Are Medicare drug plans that elect this new model required to cover all types of insulin at $35 or less co-pay?

No.  A 2021 Medicare drug plan that decides to follow the CMS model "must include at least one vial dosage form and one pen dosage form, when available as part of the Part D sponsors formulary, of each of the following: rapid-acting, short-acting, intermediate-acting, and long-acting insulins, at a maximum of $35 copay for 30 days’ supply." [emphasis added]

Here is an example of the 2021 WellCare Wellness Rx formulary showing that some insulins are covered under the $35 SSM and other insulin is covered as a Tier 5 drug.

Example of Formulary covering insulin under SSM
(source: https://wellcare.com/en/Florida/Members/Prescription-Drug-Plans-2021/WellCare-Wellness-Rx/Pharmacy/Drug-List-Formulary)

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:  Can a Medicare drug plan offer different types or forms of insulin at different co-pays?

Yes.  As noted by Medicare, the "maximum cost share for a 30-days’ supply of a Model insulin that the participating plan includes on its formulary and in this Model is $35.  [However,] Part D sponsors have the flexibility to offer a lower cost share for different types (e.g., rapid-acting, short-acting, intermediate-acting, and long-acting) and/or forms (e.g., pen, vial) of Model insulins that it is offering under the Model."

Question:  Can Medicare drug plan offer lower insulin co-pays at preferred pharmacies?

Yes.  A Medicare drug plan that decides to follow the CMS model is required to offer a variety of insulin with maximum co-pay of $35, but the plan has the option to offer the insulin for less than $35 or the Medicare plan can also offer insulin at a lower co-pay at the plan's preferred network pharmacies.

What does all this mean to me?

You will find a number of 2021 Medicare Part D prescription drug plans in your area (and possibly Medicare Advantage plans) providing coverage of insulin for a 30-day fixed cost of $35 or less throughout your drug coverage (or until Catastrophic Coverage).  You can check with the drug plans offering this coverage to see the types and forms of insulin included within the coverage.

Related Question:

If I join a Medicare plan that follows this Part D Senior Savings Model, what cost is applied to meeting our initial coverage limit, the $35 we pay for insulin or the actual drug cost?



Sources include:

https://www.cms.gov/newsroom/press-releases/cms-launches-groundbreaking-model-lower-out-pocket-expenses-insulin
https://www.cms.gov/newsroom/fact-sheets/part-d-senior-savings-model
https://innovation.cms.gov/files/x/partd-seniorsav-plan-rfa.pdf
https://innovation.cms.gov/innovation-models/part-d-savings-model
https://www.cms.gov/newsroom/press-releases/trump-administration-continues-keep-out-pocket-drug-costs-low-seniors
https://innovation.cms.gov/media/document/partd-seniorsav-cy21-spraddendum
https://innovation.cms.gov/media/document/partd-senior-savings-model-cy21-faqs





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