Starting January 1, 2023 cost-sharing for all insulin products covered under a Medicare prescription drug plan (Part D coverage) will be capped at $35 for a month’s supply. In addition, Part D deductibles will not apply to these covered insulin products.
The cap on insulin costs was introduced as part of The Inflation Reduction Act (2022) and has a significant impact on Medicare beneficiaries who rely on insulin to manage their diabetes.
How does the Inflation Reduction Act impact Medicare beneficiaries?
Prior to the implementation of the cap, many seniors were paying hundreds of dollars per month for their insulin, which made it difficult for some to afford this critical medication.
With the cap in place, Medicare beneficiaries on insulin will pay no more than $35 per month for each insulin product they use, which provides much-needed relief for those who were previously struggling to afford their medication.
For Medicare beneficiaries who use multiple insulin products, the cap on cost-sharing can result in significant savings. Some seniors use multiple types of insulin to manage their diabetes, and each product can come with a high cost-sharing amount. With the cap in place, the total cost-sharing for all insulin products combined will not exceed $35 per month, which can result in substantial savings for seniors who were previously paying much more.
Is this different to the Part D Senior Savings Model?
Yes – the Part D Senior Savings Model, was a test program introduced by the Centers for Medicare and Medicaid Services (CMS) recently announced that in 2021 that aimed to provide a similar benefit to Medicare beneficiaries. This program will end on December 31, 2023 in light of the new legislation requiring all Part D plans to cap insulin costs.
CMS Part D Senior Saving’s Model was a voluntary pilot program that for the calendar year 2021 and 2022. Plans that participated in the program offered insulin at no more than a $35 monthly copay.
The aim of the program was for the CMS, along with various participating Part D insurance plan providers and pharmaceutical companies (Eli Lilly and Company, Novo Nordisk and Sanofi-Aventis) to test the impact of giving Medicare beneficiaries better choices and options for out-of-pocket insulin costs.
While CMS will not proceed with testing the Model in CY 2024 and CY 2025, it continues to have a meaningful impact on the CMS Innovation Center’s work and longer-term goal of realizing a health care system that achieves equitable outcomes through high-quality, affordable, person-centered care.
The cap on cost-sharing for insulin products is also an important step in addressing the broader issue of healthcare affordability in the United States. Many Americans struggle to afford the cost of healthcare, and the high cost of prescription drugs is a major contributing factor. By capping the cost-sharing for insulin products, the Inflation Reduction Act is taking a concrete step towards making healthcare more affordable and accessible for all Americans.
The Inflation Reduction Act has received widespread support from a variety of stakeholders, including patient advocacy groups, healthcare providers, and policymakers. This support is indicative of the urgent need to address the issue of insulin affordability in the United States. The cap on cost-sharing for insulin products is a crucial step in this effort and represents a significant victory for patients and their families.