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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), some 2021 Medicare prescription drug plans across the country may choose to offer different types of insulin at a maximum co-pay of $35 per month throughout all phases of your drug coverage: deductible, initial coverage, and the Coverage Gap (or Donut Hole).

The 2021 coverage of $35 insulin per month 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).

However, the $35 coverage is only offered to Medicare beneficiaries who do not also qualify for the Medicare Part D low-income subsidy (LIS) - since people qualified for LIS already receive coverage for low-cost 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-costing 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.”

Question:  Will insulin cost $35 or less through all of my Medicare Part D coverage?

Yes.  A Medicare drug plan that offers the $35 (or less) co-pay insulin will keep the low cost-sharing throughout the plan coverage.

So, you will pay a $35 (or less) co-pay in the Initial Deductible, the Initial Coverage Phase, and the Coverage Gap (or Donut Hole).  If you spend over your out-of-pocket threshold ($6,550 in 2021) and enter Catastrophic Coverage, you will pay only 5% of the retail cost (so less than your $35 co-pay).


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 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. 

From initial information , a few large regional Medicare Advantage plans have already announced that they would be offering this supplemental fixed-cost insulin coverage – but, it is really too early to speculate about how many other 2021 Medicare plans across the country will offer this coverage (and what types of insulin will be covered).

Question:  Are Medicare drug plans that elects 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]

Please see the table below 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.

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

Medicare notes that the "entire drug cost should be applied in the deductible phase.  Part D sponsors are reminded of the requirement that beneficiaries move through the deductible and initial coverage phases of the Part D benefit based on the total gross [retail] drug costs accumulated, which includes costs for drugs that might not be subject to a deductible."

As background, the "'Total Gross Covered Drug Cost Accumulator' is the sum of the beneficiary‟s covered drug costs for the benefit year known immediately before the sponsor begins adjudication of an individual claim.  The Total Gross Covered Drug Cost Accumulator value moves the beneficiary through the deductible phase (if any), the initial coverage period, and into the Coverage Gap.  [Medicare plans] use The Total Gross Covered Drug Cost Accumulator in combination with the True Out-of-Pocket(TrOOP) Accumulator . . . to validate benefit phase."

You can learn more by reviewing your Medicare Part D or Medicare Advantage plans (MAPD) Evidence of Coverage document.  Here is model text that should be similar to what you find when reviewing a drug plan that provides the $35 or less insulin coverage:

"Chapter 6, Section 4.1. You stay in the Deductible Stage until you have paid $[insert deductible amount] for your [insert drug tiers if applicable] drugs."

"There is no deductible for [insert 2021 plan name] for select insulins.  During the Deductible Stage, your out-of-pocket costs for these select insulins will be $[amount or range of monthly copays for select insulins].  To find out which drugs are select insulins, review the most recent Drug List we [insert: sent you in the mail] OR [insert: 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 [Evidence of Coverage] booklet)."

What does all this mean to me?

It is possible that some 2021 Medicare Part D prescription drug plans in your area may provide coverage of insulin for a 30-day fixed cost of $35 or less, but you will need to wait until late-September or early-October to see which plans are offering coverage and what types and forms of insulin will be included with the coverage.



Heading
Type NDC Model Drug Name Dosage Form
Rapid-Acting 00024-5924-10 Admelog® 10mL Vial
Rapid-Acting 00024-5925-05 Admelog® Pen
Rapid-Acting 00024-5926-05 Admelog® 3 mL Vial
Rapid-Acting 00088-2500-33 Apidra® Vial
Rapid-Acting 00088-2502-05 Apidra® SoloStar® Pen
Rapid-Acting 00169-3201-11 Fiasp® Vial
Rapid-Acting 00169-3204-15 Fiasp® FlexTouch® Pen
Rapid-Acting 00169-3205-15 Fiasp® PenFill® cartridge Pen
Rapid-Acting 00002-7510-01 Humalog® 10 mL Vial
Rapid-Acting 00002-7510-17 Humalog® 3 mL Vial
Rapid-Acting 00002-7516-59 Humalog® Cartridge Pen
Rapid-Acting 00002-8799-59 Humalog® KwikPen® U-100 Pen
Rapid-Acting 00002-7712-27 Humalog® KwikPen® U-200 Pen
Rapid-Acting 00002-7714-59 Humalog® Junior KwikPen® Pen
Rapid-Acting 66733-0773-01 Insulin Lispro Vial
Rapid-Acting 66733-0822-59 Insulin Lispro KwikPen® Pen
Rapid-Acting 00169-7501-11 NovoLog® Vial
Rapid-Acting 00169-3303-12 NovoLog® PenFill® Pen
Rapid-Acting 00169-6339-10 NovoLog® FlexPen® Pen
Rapid-Acting 73070-0100-11 Insulin Aspart Vial
Rapid-Acting 73070-0103-15 Insulin Aspart FlexPen® Pen
Rapid-Acting 73070-0102-15 Insulin Aspart PenFill® Cartridge Pen
Short-Acting 00002-8215-01 Humulin® R 10 mL Vial
Short-Acting 00002-8215-17 Humulin® R 3 mL Vial
Short-Acting 00002-8501-01 Humulin® R U-500 Vial
Short-Acting 00002-8824-27 Humulin® R U-500 KwikPen® Pen
Short-Acting 00169-1833-11 Novolin® R Vial
Short-Acting 00169-3003-15 Novolin® R FlexPen® Pen
Intermediate-Acting 00002-8315-01 Humulin® N 10 mL Vial
Intermediate-Acting 00002-8315-17 Humulin® N 3 mL Vial
Intermediate-Acting 00002-8805-59 Humulin® N KwikPen® Pen
Intermediate-Acting 00169-1834-11 Novolin® N Pen
Intermediate-Acting 00169-3004-15 Novolin® N FlexPen® Pen
Long-Acting 0000-7715-59 Basaglar® KwikPen® Pen
Long-Acting 00088-2220-33 Lantus® Vial
Long-Acting 00088-2219-05 Lantus® SoloStar® Pen
Long-Acting 00088-5021-01 Lantus® Novaplus® Vial
Long-Acting 00088-5020-05 Lantus® SoloStar® Novaplus® Pen
Long-Acting 00169-3687-12 Levemir® Vial
Long-Acting 00169-6438-10 Levemir® FlexTouch® Pen
Long-Acting 00024-5869-03 Toujeo® SoloStar® Pen
Long-Acting 00024-5871-02 Toujeo® Max SoloStar® Pen
Long-Acting 00169-2660-15 Tresiba® FlexTouch® U-100 Pen
Long-Acting 00169-2550-13 Tresiba® FlexTouch® U-200 Pen
Long-Acting 00169-2662-11 Tresiba® Vial
Mix 00002-7511-01 Humalog® Mix 75-25 Vial
Mix 00002-8797-59 Humalog® Mix 75-25 KwikPen® Pen
Mix 00002-7512-01 Humalog® Mix 50-50 Vial
Mix 00002-8798-59 Humalog® Mix 50-50 KwikPen® Pen
Mix 00002-8715-01 Humulin® 70-30 10 mL Vial
Mix 00002-8715-17 Humulin® 70-30 3 mL Vial
Mix 00002-8803-59 Humulin® 70/30 KwikPen® Pen
Mix 73070-0200-11 Insulin Aspart Mix 70/30 Vial
Mix 73070-0203-15 Insulin Aspart Mix 70/30 FlexPen® Pen
Mix 00169-1837-11 Novolin® 70/30 Vial
Mix 00169-3007-15 Novolin® 70/30 Pen
Mix 00169-3685-12 NovoLog® Mix 70/30 Vial
Mix 00169-3696-19 NovoLog® Mix 70/30 FlexPen® Pen
Combination 00024-5761-05 Soliqua™ 100/33 Pen
Combination 00169-2911-15 Xultophy® Pen


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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