New Medicare Plan Will Cap Insulin Copays at $35


Today, the Centers for Medicare & Medicaid Services (CMS) launched a new plan for some Medicare Part D participants to pay a maximum $35 copay for their monthly supply of insulin.

The program is called the Part D Senior Savings Model and applies to participating Part D enhanced plans through Medicare. These enhanced plans have slightly higher premiums (an average of $49.32 per month versus $32.09 per month) than the standard Part D plan, but offer broader prescription drug coverage.

Only insulins created by participating manufacturers will be included, but the intent is for all types of insulin to be covered, including long-acting, intermediate-acting, short-acting and rapid-acting. As of March 11, Lilly has signed on to participate in this program once it launches on January 1, 2021. CMS is currently inviting other manufacturers to apply by March 18, 2020 to be included in the 2021 plan.

A copay cap provides consistent and predictable access to insulin, allowing insulin-dependent people with diabetes the ability to create reliable budgets for their medication needs. This is different from the current model in which Medicare Part D beneficiaries are often faced with fluctuating prescription costs month to month.

CMS reports that those enrolled in a participating plan should save “an average of $446 in annual out-of-pocket costs for insulin.” While the new model applies to a small part of the population, it reduces a significant burden for some of the most vulnerable members of the population: insulin dependent people with diabetes over the age of 65. The plan also creates a model for how copay caps may be done in future.

Insulin rationing due to unpredictable or inaccessible costs is dangerous for everyone with insulin-dependent diabetes, potentially leading to complications such as nerve damage, amputation, diabetic ketoacidosis and even death.

More information on the new Part D Senior Savings Model can be found here.

WRITTEN BY Lala Jackson, POSTED 03/11/20, UPDATED 10/03/22

Lala is a communications strategist who has lived with Type 1 diabetes since 1997. She worked across med-tech, business incubation, library tech and wellness before landing in the T1D non-profit space in 2016. A bit of a nomad, she grew up primarily bouncing between Hawaii and Washington state and graduated from the University of Miami. You can usually find her reading, preferably on a beach.