However, 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. That led to a short video that played during a May 26, 2020, briefing by President Donald Trump in the Rose Garden, as part of the announcement of a new $35 insulin copay cap for certain Medicare.
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 (the toll-free number is on most plan information, the Member ID card, and the plan's website).
2. Review the Medicare plan's Evidence of Coverage document or Formulary (drug list).
For example, If you 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 Part D or Medicare Advantage Plan Finders.
As noted above, Medicare Part D plans or Medicare Advantage plans offering the $35 or less insulin will show the text 'select insulin pay $35 copay' (or $25 or $11 co-pay depending on the plan) or if we do not know the co-pay: '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).
We have a 'filter' at the top of the search box so you can check 'Insulin $35 or less plans' to only see Medicare plans that include the Senior Savings Model (for example, 10 Medicare Part D plans in Florida).
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.
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?
WASHINGTON (AP) — Many Medicare recipients could pay less for insulin next year under a deal President Donald Trump announced Tuesday in a pivot to pocketbook issues important in November’s election.
“I hope the seniors are going to remember it,” Trump said at a Rose Garden ceremony, joined by executives from insurance and drug companies, along with seniors and advocates for people with diabetes.
The deal comes as Trump tries to woo older voters critical to his reelection prospects.
How To Get Cheaper Insulin On Medicare
Medicare recipients who pick a drug plan offering the new insulin benefit would pay a maximum of $35 a month starting next year, a savings estimated at $446 annually. Fluctuating cost-sharing amounts that are common now would be replaced by a manageable sum.
The insulin benefit will be voluntary, so during open enrollment this fall Medicare enrollees who are interested must make sure to pick an insurance plan that provides it. Most people with Medicare will have access to them.
$35 Insulin Medicare
Administration officials are hoping the announcement will provide a respite from the grim drumbeat of coronavirus pandemic news.
Stable copays for insulin are the result of an agreement shepherded by the administration between insulin manufacturers and major insurers, Medicare chief Seema Verma told The Associated Press. The three major suppliers, Eli Lilly, Novo Nordisk and Sanofi, were all involved.
“It was a delicate negotiation,” Verma said. Drugmakers and insurers have been at odds in recent years, blaming one another for high prices. “I do think this is a big step.”
The cost of insulin is one the biggest worries for consumers generally concerned about high prices for brand name drugs. Millions of people with diabetes use insulin to keep their blood sugars within normal ranges and stave off complications that can include heart disease, blindness, kidney failure and amputations. People with diabetes also suffer worse outcomes from COVID-19.
An AP-NORC poll this month found warning signs for Trump with older voters. Fifty-four percent of adults 60 and older said they disapproved of how Trump is handling his job as president, while 45% approved.
On Tuesday, Trump tried to suggest former President Barack Obama was responsible for high drug prices. And he took a dig at former Vice President Joe Biden, who’s running to deny him a second term. “Sleepy Joe can’t do this,” Trump said.
The president last week told Republican senators at a Capitol Hill meeting he still wants to pass a bill this year to lower drug costs, saying “I think you have to do it,” according to a summary from an attendee. Bipartisan legislation to limit price increases and reduce costs for older people with high drug bills is pending in the Senate.
But the fate of any drug pricing bill seems to rest with House Speaker Nancy Pelosi, who has a much more ambitious plan for Medicare to negotiate prices for the costliest drugs, not just insulin. Pelosi would use expected savings to provide vision, dental and hearing coverage for older adults. Most Republicans oppose that approach as an expansion of government price-setting.
Although the White House and Pelosi’s office were in conversations last year about action on drug prices, the relationship between the two leaders has been tense and angry for months.
White House Counselor Kellyanne Conway told AP the administration can’t wait for the Democratic-controlled House on drug prices. “Waiting for them to act is very perilous,” Conway said.
Verma, head of the Centers for Medicare and Medicaid Services, said 1,750 insurance plans that offer drug coverage to Medicare recipients have agreed to provide insulin for a maximum copay of $35 a month next year. It will be available through “enhanced” plans that may cost more per month but offer additional benefits such as reduced cost-sharing on certain drugs. The cap on copays is expected to lead to a small increase in premiums.
Importantly for patients, the new benefit would cover a range of insulin products, including pen and vial forms for rapid-acting, short-acting, intermediate-acting and long-acting versions.
One out of three people with Medicare have diabetes, and more than 3 million use insulin. At list prices, the drug can cost more than $5,000 a year. Although insured patients don’t pay that, they do notice rising copays that are based on the full cost. People who can’t afford their insulin may try to cope by reducing their doses, a dangerous calculation that can put their lives in jeopardy.
Medicare’s prescription drug benefit is offered by private insurers, either as a stand-alone “Part D” drug plan added to traditional Medicare, or as part of a managed care plan under Medicare Advantage. The taxpayer-subsidized private plans are closely regulated by the government, but by law Medicare is barred from negotiating drug prices — something Democrats including Biden want to change.
Insurers and drugmakers welcomed the announcement. The industry group America’s Health Insurance Plans called it an “excellent example of public-private partnerships where everyone wins.” The Pharmaceutical Research and Manufacturers of America said it’s pleased to see the administration focused on lowering out-of-pocket costs for patients.
Medicare estimates that about 6 in 10 beneficiaries are already in prescription drug plans that will offer the new insulin benefit. Those whose plans don’t offer the new option can switch during open enrollment season, which starts Oct. 15. Medicare’s online plan finder will help beneficiaries find plans that cap insulin copays.
The insulin benefit will be available in all 50 states, Washington, D.C., and Puerto Rico. Participation is voluntary for insurers and Medicare recipients alike.
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Associated Press writer Hannah Fingerhut contributed to this report.