Do you have questions about Medicare Part D? Are you aging into Medicare or currently considering a new plan due to your use of Insulin? This article answers common questions about Insulin Coverage on Medicare Part D.
Insulin Savings Common Questions & Answers
Q: What is the Part D Senior Savings Model?
A: The Part D Senior Savings Model allows participating Part D prescription drug plans to offer a broad set of formulary insulins at a maximum $35.00 copayment per month’s supply, throughout the deductible, initial coverage, and coverage gap phases of their Part D drug coverage. This means that participating Part D plans offer enrollees predictable, stable copayments for insulin to help enrollees save money on their drug costs.
Q: What kinds of plans can participate in the Part D Senior Savings Model?
A: Most Medicare Part D plans that people choose from during Open Enrollment can participate in the Model. This includes stand-alone Medicare Part D Prescription Drug Plans (PDPs) as well as Medicare Advantage Prescription Drug plans (MA-PDs) that offer enhanced alternative Part D coverage. Private fee-for-service plans (PFFS plans), employer/union only direct contract plans (local coordinated care plans, prescription drug plans, PFFS plans), section 1876 cost contract plans, dual-eligible special needs plans (D-SNPs), section 1833 health care prepayment plans, Program of All-Inclusive Care for the Elderly (PACE) organizations, Medicare-Medicaid plans, and religious fraternal benefit plans (local coordinated care plans and PFFS plans) aren’t eligible to participate in the Model.
Q: What plans are part of the Model? How do I find one?
A: The Centers for Medicare & Medicaid Services (also known as CMS, the federal agency that approves Medicare plans) announced Medicare Advantage plans with prescription drug coverage (MA-PD) and Part D prescription drug plans (PDPs) that are participating in the Model for Calendar Year (CY) 2022 in September 2021. You can call 1-800-
MEDICARE to ask questions about enrollment, eligibility, and the Model, or visit Medicare Plan Finder at https://www.medicare.gov/plan-compare/ to search for coverage in your area and compare Part D plan options with the lowest prices for your prescriptions. You can also find a list of participating plans on the Model website at:
Q: When is the Part D Senior Saving Model expected to end? How many years is the model?
A: Since CMS is testing the Part D Senior Savings Model to lower costs and improve health care quality, it has a set period for when it’s available. Part D plans participating in the Model first became available on January 1, 2021. The Model extends until December 31, 2025, but the plans participating in the Model may change each year.
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Q: How do I know if my plan from CY 2021 will be participating again this year?
A: If you joined a plan participating in the Part D Senior Savings Model for 2021, your plan will notify you in the Annual Notice of Change (ANOC) that you’ll receive in September 2021 if they’re no longer participating. If you’re interested, you can choose a different plan for 2022 during the Medicare Open Enrollment Period starting in October 2021.
Q: Will the member be offered a plan with a higher premium so they can get their insulin at a lower ($35.00) cost?
A: The Part D Senior Savings Model allows drug manufacturers to offer their discounts in the coverage gap, even when a Part D plan enhances cost sharing. This allows plans to offer a fixed, consistent cost sharing on insulin. This structure is estimated to save enrollees who take insulin $446 in annual out-of-pocket costs. Part D sponsor plan premiums vary and beneficiaries should find a Part D plan that provides them the coverage they want at the lowest total annual cost, premiums and out-of-pocket costs combined.
Q: What insulin drugs are covered under the Model?
A: Part D sponsors are required to include at least one vial and pen dosage form for each of the different types of Model insulins, where available – rapid acting, short-acting, intermediate-acting and long-acting – at a maximum $35 copay for a one-month supply through the deductible, initial coverage, and coverage gap phases of the benefit. Part D sponsors are encouraged to include additional insulin formulations, such as concentrated insulins, at the same $35 copay for a one-month supply. The Model doesn’t affect the cost sharing of insulin covered under Part B. For a full list of the insulin drugs covered by each plan, as well as which drugs are covered under the Model, beneficiaries should review the drugs’ cost sharing on Medicare Plan Finder, as well as check the plan’s formulary.
Q: Will step therapy apply with insulin drugs?
A: Step therapy is when a Part D plan requires enrollees to first try certain drugs to treat a medical condition before the plan will cover another drug for that condition. The Model doesn’t change Part D sponsors’ formulary requirements. Enrollees can find out if the insulin or insulins they use have any additional step therapy requirements or limits by looking at the Part D plan’s formulary.
Q: If a beneficiary has Low-Income cost-sharing Subsidy (LIS), sometimes called Extra Help, are they eligible for the $35 per month cost sharing under the Model?
A: Part D enrollees who receive LIS already have a set Part D copayment, so they aren’t eligible for the $35 per month’s supply copayment under the Model. This includes Partial LIS, or LIS 4, enrollees.
Q: Will Senior Savings Plans have a full formulary?
A: Yes. The Part D Senior Savings Plans are enhanced alternative Part D plans, so they have a full formulary and cover Part D benefits.
Q: Is there a cap on the number of units monthly to get the $35.00 copay?
A: Generally, the maximum $35.00 copayment under the Model applies to one month’s supply of insulin. This may be limited by a physician’s prescription or by plan rules on drug dosage to ensure patient safety. Please note that if an enrollee uses multiple types of insulin or has multiple prescriptions for select insulins covered under the Model, each prescription would have a copayment of a maximum $35.00 for a one month’s supply.
Q: If a Model insulin is on a participating plan’s formulary tier where a deductible applies, will the deductible apply to Model insulins on that formulary tier?
A: No, the deductible does not apply to select Model insulins that have a maximum copay of $35 per one-month supply. The deductible would apply to all other drugs on the tier.
Q: Is the Model cost sharing for insulin applicable in the catastrophic phase of the Part D benefit?
A: No, the Model doesn’t test any changes or cost sharing in the catastrophic phase. In the catastrophic phase, non-Low Income cost-sharing Subsidy (LIS) beneficiaries generally pay a 5% coinsurance on all drugs.
Source: CMS.gov Insulin Savings Program Frequently Asked Questions. Sourced 10.26.21. From Part D Senior Savings Model Insulin Savings Common Questions and Answers (cms.gov)