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Medicare Insulin Senior Savings Program

Which Plans Are Eligible For The Part D Senior Savings Model

Medicare Insulin Savings

Medicare Advantage plans and Medicare Part D prescription plans allow you to take advantage of the Part D Senior Savings Model.

To find out if your prescription drug plan or Medicare Advantage plan participates in the program you can use theMedicare Plan Finder on Medicares website.

Currently, the rule spells out $35 for a months supply, but there is not a listed number of units covered under the model.

Medicare Coverage For Insulin

For most Medicare beneficiaries insulin is covered under Medicare Part D. Medicare Part D is coverage for prescription drugs. Most insulins come in a vial and are loaded into a syringe or a preloaded injectable pen.

For beneficiaries that use an insulin pump, their insulin can be covered under Medicare Part B. An insulin pump is covered as durable medical equipment and the insulin could be covered under Medicare Part B.

Before the Senior Savings Model took effect the insulin costs would vary for beneficiaries based on several factors. One factor is which stage of their drug coverage they are in. In some phases, the cost may be a $35 to $100 copay. In other phases, they would have to pay a percentage of the full cost of the drug. Many times insulin is $300 to $1000 a month, so 25% of the cost is often prohibitive for many people.

With Part D coverage, regardless of whether you enroll in a standalonePart D plan, or receive your drug coverage from a Medicare Advantage plan, you could be responsible for premiums, deductibles, copays, or coinsurance.

Medicare Part D coverage

As mentioned above Medicare Part D consists of several phases of coverage. Each plan has a different formulary, or list of what drugs are covered. All plans are required to cover at least one prescription drug in each therapeutic class. This Medicare Part D coverage phases are:

  • Deductible Phase: You pay the total amount of the prescription until the deductible is met.
  • Medicare Advantage drug coverage

    New Options For Affordable Insulin

    In the United States, there are 37.3 million people with diabetes. And for many, diabetes is an expensive and complex medical condition, often requiring multiple medications including insulin and regular doctor visits. In fact, diabetes is the most expensive chronic condition in the nation. The annual cost of diagnosed diabetes is an estimated $327 billion and climbing.

    Medicare Part D has helped seniors and other Medicare beneficiaries save billions of dollars on their prescription costs over the last two decades. But still, total out-of-pocket spending on insulin for Part D enrollees was $1 billion in 2020.

    For these consumers, a change was needed.

    Current savings: The insulin demo

    In March 2020, Centers for Medicare & Medicaid Services announced a new Part D Senior Savings Model for Medicare beneficiaries who use insulin. Plans voluntarily participated in this model to provide seniors a low stable, predictable insulin copay. This helped members who did not already receive Extra Help and were enrolled in participating Medicare insurance plans with prescription drug coverage. Their monthly out-of-pocket costs for insulin reduced to $35 or less per covered prescription during three phases of coverage: the deductible phase, the initial coverage phase and while in the coverage gap.

    Each of the three major insulin manufacturers and 76 Part D sponsors covering about 2,500 insurance plans are participating in the program.


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    Blue Cross Medicare does not cover dental implants. Blue Cross Blue Shield is called Florida Blue in Florida.Blue Cross Medicare Advantage HMO, PPO and D-SNP plans do not cover dental implants. Dental implants are excluded from all plans.

    Hereâs a screen shot from the Blue Cross Medicare Advantage evidence of Coverage that shows dental implants are not a covered service.

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    Medicare And Dental Coverage

    Original Medicare and Medicare Supplement insurance do not cover routine dental care. Overall, it is difficult to find yourself in a situation where your Medicare plan will cover. But, there are a few instances:

    • You need a dental exam before surgery, like a heart valve replacement.

    • Youve sustained an injury to your jaw or mouth that results in tooth damage.

    • Youre undergoing treatment for oral cancer.

    In all of these cases, you will be covered under Medicare Part A, which covers you for hospital visits. Bear in mind that this doesnt mean youll get dental implants if you lose a tooth in an injury. Medicare Part A likely only covers the tooth extraction.

    Additionally, follow-up dental appointments may not be covered under your Original Medicare plan.

    Supplemental Dental Insurance For Braces

    If children have crooked, misshapen, or malformed teeth it may cause long-term medical problems with their jaw or make it impossible for them to bite or chew correctly². If its determined that your child needs braces for medical reasons your Insurance may cover the cost of the braces but note that braces are part of the overall costs of orthodontics. You still need to pay for the cost of the visits to the orthodontist and the cost of retainers and other equipment not covered under your dental insurance.

    If you know that youre going to need supplemental insurance for your kids you shouldnt wait to purchase a supplemental plan. Some plans have waiting periods, so buying supplemental insurance now can help ensure that the waiting period will be finished by the time your child needs braces. If you need to get dental care for yourself or your child immediately look for a dental plan with no waiting period.

    Another thing to keep in mind when youre purchasing supplemental insurance for braces and orthodontics is that some supplemental plans wont cover treatment that started before you enrolled in the program. So you should wait until you have purchased insurance to start your childs orthodontic treatment to make sure its covered.

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    Senior Savings Model Insulin List

    Not all brands of insulin or drug manufacturers have agreed to participate in the model. Below is a list of the participating drug companies. This list is based on the 2022 participating manufacturers. The participating providers for 2023 could be different.

    • Eli Lilly and Company
    • Mylan Specialty L.P., a Viatris Company
    • Sanofi-Aventis U.S. LLC

    Remember that not all plans are participating. Use the Medicare Plan Finder found on Medicare.gov to verify if your plan is participating. Part D plans that are available and participating are listed above.

    How Do People With Medicare Afford Insulin

    Medicare Insulin Savings – Testimonial

    According to the CDC, more than 37 million Americans are living withdiabetes. That is a staggering 11% of the population. As far as Medicare is concerned nearly 32% of beneficiaries are affected by diabetes.

    In many cases, these individuals are reliant on taking insulin to control their diabetes. Over the years the cost of insulin has increased steadily. Today it is so high that its not uncommon for beneficiaries to choose between their meals or their medication.

    The cost of insulin increased by more than 1,000% between 1999 and 2019. Part of the reason for the increase is that there are not that many suppliers of insulin in the United States.

    High demand coupled with the complexity of formulation allows pharmaceutical manufacturers to raise prices without much of a repercussion.

    The rising costs havent slowed down, with out-of-control inflation creeping into every aspect of our lives. But at least with the new Part D Senior Savings Model, there is at least a glimmer of hope on the horizon.

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    Proposals To Address Insulin Costs For Medicare Beneficiaries

    Innovation Center Model

    In March 2020, the Administration announced a voluntary Innovation Center model, the Part D Senior Savings Model, that allows participating Part D plans to offer coverage of insulin for a flat monthly copayment of no more than $35 for enrollees not receiving low-income subsidies , starting in 2021. Participating Part D plans enhanced plans only, not basic plans can offer insulin products from participating manufacturers at a flat $35 copayment during all phases of the benefit . Compared to basic Part D plans, enhanced plans can offer a lower deductible , reduced cost sharing , and/or a higher initial coverage limit .

    CMS recently announced that more than 1,750 enhanced Part D plans will participate in the model in 2021 for reference, this equals roughly 50% of all enhanced plans in 2020, including both Medicare Advantage and stand-alone drug plans and roughly 40% of all Part D plans this year. It is not yet known how many Part D plans of each type will be offered in 2021, or how many plans in total.

    Example of Part D Plan, Manufacturer, and Enrollee Costs For a Monthly Prescription Drug Fill in the Coverage Gap Under Current Law With and Without Supplemental Benefits and Under the Administrations Part D Model
    Under current law with no supplemental benefit Under current law with a $35 monthly copay in coverage gap Under Administrations Part D model with a $35 monthly copay
    List price
    $115$500 $350 $35
    Implications for Part D Enrollees

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    Insulin Benefits With A Clover Health Medicare Advantage Plan

    Central Oregon Insurance

    Clover Health is dedicated to helping you manage diabetes. Thats why were participating in the Medicare Part D Senior Savings Model, which offers cost savings for insulin.

    The Senior Savings Model lowers the cost of insulin by setting a $35 maximum copay for a one-month supply of insulin. This applies through the different Part D benefit coverage stages. Catastrophic stage cost share would still apply. Your insulin will cost no more than $35 per month even if you havent reached your yearly deductible.

    The cost also stays the same during the coverage gap, so your insulin costs wont increase.

    If youre enrolled in a Clover Health plan participating in the Senior Savings Model, youll only pay:

    • $25 per month for select insulins at preferred network pharmacy
    • $35 per month for select insulins at standard network pharmacy

    Being able to pay as little as $25/month for select insulins with no deductible allows our members to save about $446 in out-of-pocket costs for the year. To find out which drugs are Select Insulin Drugs, review the 2022 Drug Formulary.

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    Medicare Plan Finder Likely Wont Note New $35 Cap On Out

    By Susan JaffeNovember 15, 2022

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    Does Medicare Pay For Insulin

    The cost of your insulin, insulin pens, and insulin pumps depends on several factors:

    • Your Medicare coverage and any supplemental coverage
    • The type of insulin youre using
    • How much of the medication you use each month or year
    • Whether your Medicare drug plan requires a coinsurance or copayment for this medication
    • Your income level and the state you live in
    • The pharmacy you use to fill prescriptions

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    Medicare Part B Costs

    Medicare Part B requires a monthly premium for medical coverage, which you must pay in order to be covered. The actual cost varies depending on your income level.

    In 2022, most people who are enrolled in Medicare Part B will pay a premium of $158.50 per month . However, if your income is above a certain threshold, you may have to pay more than that amount.

    There are also deductibles to consider, along with coinsurance. The Medicare Part B deductible is currently set at $217 for the year 2022 . Youre responsible for paying this deductible amount before Medicare will begin to pay. After that, youre responsible for paying 20% of the Medicare-approved amount for your healthcare expenses and services unless you have a supplemental plan that would cover the rest.

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    According to the American Diabetes Association, as of 2018, there were 14.3 million seniors age 65 or older with either diagnosed or undiagnosed diabetes. The Centers for Disease Control and Prevention reports that diabetes diagnoses among this age group more than doubled from 2000 to 2010.

    With age being a risk factor for developing Type 2 diabetes, many expect to see a trend of higher insulin use among seniorsmainly related to the increase in the senior population. It wasnt until 2006 that Medicare began covering a portion of most prescription drugs, including insulin, for Medicare consumers diagnosed with diabetes. Prior to that, Medicare generally only paid for prescription drugs that were administered in a physicians office or in a hospital or skilled nursing facility.

    Recently, in 2021, Medicare rolled out a new insulin saving program for Part D plans called the Senior Savings Model. The new program offers insulin coverage at no more than $35 per month for Medicare Part D consumers with diabetes. These changes will help combat the rising costs of insulin and decrease out-of-pocket expenses for seniors with diabetes.

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    Optional Changes To Risk Corridors

    • Existing Part D Risk Corridors: Under the Part D risk corridors, if a plans adjusted allowable risk corridor costs exceed its target amount for a plan year by more than the first threshold limit , the federal government pays the plan 50 percent of the excess up to the second threshold limit .
    • Optional Changes Under Model: The Model provides that, during the first two years of the Model , a participating plan sponsor has the option to opt-in to a modification of the risk corridors under which the first threshold would be reduced from 5 percent to 2.5 percent if the plan has a statistically significantly greater number of insulin-dependent diabetic enrollees on at least one Model Drug than similar plan types.
    • As a result, CMS would share 50 percent of excess costs beginning at a 2.5 percent threshold, rather than a 5 percent threshold, for plans to which these changes apply. Conversely, plans whose costs fall short of the target amount would be required to share 50 percent of savings with CMS beginning at 2.5 percent below the target amount, rather than 5 percent.
    • Note that adjusted allowable risk corridor costs include costs for essentially all drugs covered under a plan, and as such the calculation is not limited to costs for insulin products.

    Is There A Limit To The Amount Of Insulin Eligible For The Maximum $35 Copay Plan

    The maximum $35 copayment is applied to one months supply of insulin. Those limits are set by the physicians prescription itself. There are plan rules on drug dosage that limit the monthly amounts to ensure the safety of the patient. If someone takes multiple types of insulin each month, each prescription would be eligible for the maximum $35 copay, not all combined.

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    How To Enroll In The Program

    Medicares open enrollment for coverage year 2022 will be from October 15th December 7th. Check for participating plans in your area at Medicare.gov. Look to see what each Medicare plan will charge you out-of-pocket for your medications, and seek out the lowest cost plan available. You can also call 1-800-MEDICARE to ask questions about enrollment, eligibility, and the program itself.

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