$35 max copays on insulin for Medicare beneficiaries in 2021

Diabetes is a deadly disease that has afflicted people worldwide for thousands of years. Diabetes is the seventh leading cause of death in America that accounts for nearly 80,000 deaths each year, according to the CDC. Humans naturally make insulin in their pancreas, but diabetics struggle to produce their own insulin, which is deathly. Senior citizens struggle with this disease due to age and the cost of insulin.

There are over 14 million Medicare beneficiaries who have diabetes, and over 3 million use at least one form of insulin. Considering diabetes is one of the deadliest diseases in America, you would assume that drug manufacturers would offer insulin at a reasonable price. In 2020, the cost for one vial of insulin can cost up to $250, and keep in mind that some diabetics need more than one vial a month.

The price of insulin is inconsistent and fluctuates throughout the year. When seniors live on a fixed income, the inconsistency makes it hard to save and budget. Having access to insulin is critical, and some seniors have resorted to rationing their insulin each month or flat out not receiving it. Diabetics who do not receive insulin can have major complications, such as vision loss, kidney failure, and potentially death.

On March 11, 2020, the Trump Administration announced the Part D Senior Savings Model and how it will bring stability and predictable insulin costs to Medicare beneficiaries in 2021.

The Part D Senior Savings Model

The Part D Senior Savings Model is a voluntary option for Part D sponsors that will cap the maximum out-of-pocket spending for insulin at $35 for a month’s supply. CMS is enabling Part D plans to offer predictable copays for beneficiaries, which is what seniors struggle with the most.

Since the Model’s introduction, over 1,700 Medicare Part D and Medicare Advantage plans (also known as Medicare Part C) have applied to offer the new insulin costs through the Model in the upcoming year. The Model is projected to save seniors $446 for their insulin, which some seniors pay for a month’s supply.

Part D participant requirements

There are special requirements that must be met to participate in the new Part D Model. The Part D sponsors and Medicare Advantage plans that participate must add both pen and vial dosage for each type of insulin on the drug formulary. Long-acting, short-acting, intermediate-acting, and rapid-acting are the four types of insulin, and each must be included within the formulary.

When drug plans enroll in the Model, the Part D sponsors, and Medicare Advantage plans cannot increase the $35 copay and must provide the beneficiary with a 30-day supply. Drug manufacturers who participate in the Model must offer all insulin products to the Part D sponsors and cannot exclude any for any reason.

Insulin manufacturers and Part D sponsors will compete with one another; therefore, you may find a Part D plan with a copay lower than $35 a month. The Model will offer seniors a variety of Part D options that will cover their insulin and lower the annual out-of-pocket spending by 66 percent.

Enrolling in the Part D Senior Savings Model  

Your time to drop, change, or switch your Medicare Advantage or Part D plan will take place during the Annual Election Period. The AEP will take place on October 15, 2020 and will end on December 07, 2020. The CMS predicts that the Model will be available in all 50 states, including Puerto Rico and the District of Columbia, through either a Part D or Medicare Advantage plan.

In September 2020, CMS will release premiums and insulin copays for the year 2021. You will be able to research and find participating sponsors by utilizing the Medicare Plan Finder tool on Medicare’s website. The Medicare Plan Finder tool will filter out the non-participating plans and will provide you with prices for each plan in the Model. When researching the various plans, you will want to ensure the one you enroll in has all or most of your needed drugs listed on the formulary.

If the new Model is a success, the Trump Administration hopes to expand this Model and include other drugs. Offering a $35 max copay on insulin for Medicare beneficiaries is a huge step in helping senior diabetics receive the insulin they well deserve and help save money throughout the ye

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