In May, the Center for Medicare and Medicaid Services announced a new nationwide Medicare prescription $35 cap on insulin co-pays, even during “the donut hole.” This is good news for many insulin-using Medicare beneficiaries, but there are some things to know about this new cap. The insulin savings does not take effect until 2021. 

Not every Part D or Medicare Advantage plan has agreed to participate in the insulin savings programs. At the time of the announcement, a total of 88 insurers had agreed to participate with a total of 1,750 different drug coverage plan options. More plans may opt in before Open Enrollment begins on October 15. 

People will have to choose one of these new “enhanced” plans to get the savings, and the savings may not be included in many of the lower premium plans offered. You may have to pay a higher monthly premium to get the lower insulin copays.  

Plans may be able to dictate which brands of insulins they offer at the reduced rate—so patients may have to switch to a different insulin to get the savings. NON-insulin injectable diabetes medications like Victoza, Trulicity, and Ozempic, among others, are NOT part of this new pricing program.

We will know much more about the premium rates and which plans have opted in once the 2021 rates are published in September of 2020.  

Plan on comparing Part D or Medicare Advantage plans this open enrollment if you use insulin. Medicare Part D Open Enrollment runs October 15 through December 7 each year. MMAP can help. Call 1-800-803-7174 for MMAP or learn more at Medicare.gov.

About Author

Leave Comment