Q&A About Insulin Price Changes

Posted by Janet Phipps
Estimated Reading Time 1 minute 50 seconds

A new law aimed at reducing prescription drug costs for millions of Medicare beneficiaries has introduced a significant provision: a $35 monthly cap on out-of-pocket expenses for insulin covered by Part D prescription drug plans and Medicare Advantage (MA) plans that include drug coverage.

Here are some answers to common questions regarding this new Medicare benefit.

Q: Do I need to have Type 1 or Type 2 diabetes to be eligible for this benefit?

A: No. As long as the insulin prescribed by your doctor is covered by your Medicare drug plan, you won’t pay more than $35 a month for it.

Q: Does the specific insulin I take matter?

A: Yes. Not all Medicare plans cover every type of insulin. If your insulin isn’t covered by your Medicare Part D or Medicare Advantage plan, consider asking your provider if you can switch to a covered option. With over 70 insulin types available, your prescription may vary based on your diabetes type and other health factors.

Q: Does the method of insulin administration affect the benefit?

A: Yes, in terms of when the cap takes effect. For Medicare enrollees using vials, syringes, or prefilled pens (typically covered under Part D or an MA plan), the $35 cap began on Jan. 1, 2023. If you use a pump (covered under Medicare Part B), the cap begins on July 1, 2023.

Q: What if I receive insulin through a pump?

A: Insulin via pump falls under Medicare Part B. The $35 copay cap for Part B starts on July 1, 2023, and the Part B deductible won’t apply.

Q: Does the $35 cap cover other diabetes-related expenses?

A: No. The cap applies only to insulin. Costs for other medications and supplies, such as test strips or glucose monitors, depend on your Part D or Medicare Advantage plan.

Q: Can I change my drug coverage to benefit from this cap?

A: Yes. Due to the law’s timing after plan premiums and copays were set for 2023, a Special Enrollment Period has been established until Dec. 31, 2023, for beneficiaries to reconsider their prescription plans and potentially find better deals.

Q: How can I find out if I can get a better deal?

A: You have two options. You can call the Medicare hotline at 800-MEDICARE (800-633-4227), staffed 24/7. Alternatively, contact the State Health Insurance Assistance Program (SHIP) in your state. SHIP counselors can assist in reviewing your current plan and exploring alternatives to save you money, making the switching process easier.

And, of course, Medicare Advantage members should remember that you can always call your provider’s customer service line. They can answer your questions and help you manage your prescription costs.