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The big three insulin producers are Eli Lilly and Company, Novo Nordisk A/S, and Sanofi S.A., in which they dominate more than 90% of the world insulin market by value, SWFI reports. Indeed, these three companies will benefit greatly from the freeze. Interestingly enough, during the 2020 election cycle Eli Lilly gave $138,880 to Joe Biden. Most Medicare Enrollees May Soon Only Pay $35 A Month For Insulin Older adults 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.
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- The Centers for Medicare and Medicaid Services (CMS) recently announced that in 2021, over 1,600 Medicare Part D prescription drug plans will offer lower insulin costs. In particular, these will offer insulin at no more than a $35 monthly copay beginning on January 1, 2021.
- Lilly unites caring with discovery to create medicines that make life better for people around the world.
Insulin Savings For Medicare Part D Members
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).
For more information about the $35 insulin coverage and examples of how to find plans with $35 insulin coverage, please see our Frequently Asked Question 'How will I know if my Medicare Part D drug plan covers insulin for $35 or less?'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?
Lilly Insulin 35 Dollars