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Will all 2024 Medicare drug plans cover formulary insulin for only $35 per month (or less)?

Category: Insulin and Diabetic Supplies
Updated: Jan, 06 2024


Yes.  The Inflation Reduction Act (IRA) requires that a 30-day supply of any insulin product on a 2024 Medicare Part D prescriptions drug plan's formulary is covered at a maximum $35 copay throughout all phases of your Medicare Part D plan coverage: Initial Deductible (if any), Initial Coverage phase, and the Coverage Gap (Donut Hole).

As a practical note, many Medicare Part D drug plans will offer some formulary insulin products for a copay of less than $35 (for example, a $20 copay for a 30-day supply).

If you have higher out-of pocket expenses (over $8,000), and exit the 2024 Coverage Gap, you will have no additional costs for any formulary drugs (including insulin) for the remainder of the year.

As a reminder, beginning in 2024, the IRA eliminates beneficiary cost-sharing during the Catastrophic Coverage phase.  In 2025, the IRA will eliminate the Coverage Gap as the third part of Part D drug coverage and a Part D beneficiary will not have any additional expenses for formulary drugs after spending $2,000 out-of-pocket.

The IRA's $35 insulin copay is similar to the 2021-2022 Senior Savings Model coverage.  However, unlike the earlier Senior Saving Model, the Inflation Reduction Act of 2022 expands the insulin $35 copay to all Medicare Part D prescription drug plans or Medicare Advantage plans offering prescription drug coverage (MAPDs) and includes all Part D forms of insulin found on a drug plan's formulary or drug list.

As a note, since June 2023, insulin furnished through Medicare Part B durable medical equipment (DME) coverage (such as used in insulin pumps) will also have a monthly copay of no more than $35.

Finally, starting in 2026, the United States government can begin negotiating drug prices directly with pharmaceutical companies, so the future copay for insulin may be less than $35 depending on the government's negotiated price.


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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