With the implementation of the Inflation Reduction Act, diabetes patients are wondering what changes they can expect in their insulin coverage in 2023 With the constant evolution of the healthcare industry, it is important to stay informed about any updates that may impact your health and wellbeing. In this article, we will delve into the details including changes, updates, and what to expect for diabetes patients.
Medicare Part B (Medical Insurance) excludes coverage for the following:
- Insulin (unless it’s medically necessary to use an insulin pump)
- Insulin pens
- Syringes
- Needles
- Alcohol swabs
- Gauze
On the other hand, Part D covers prescription drugs, including insulin and related supplies, and offers extra coverage to help lower drug costs. Medicare-approved private plans provide this additional coverage.
However, the following are covered by Medicare Part D(Prescription Drug):
- Injectable insulin that is not used with a traditional insulin pump
- Insulin used with a disposable insulin pump
- Certain medical supplies used for insulin injection, such as syringes, gauze, and alcohol swabs.
What is the cost of insulin under Original Medicare?
Under Original Medicare, the amount you pay for insulin is limited. Each Part D-covered insulin has a maximum cost of $35 for a one-month supply, and you are not required to pay a deductible for insulin. This cost limit applies to all individuals who use insulin, regardless of whether or not they receive Extra Help. If you opt for a 60- or 90-day supply of insulin, you will not be charged more than $35 for each month’s supply of each covered insulin. For instance, if you obtain a 60-day supply of a Part D-covered insulin, your payment will generally be capped at $70.
Insurance plans have until the end of March 2023 to modify their systems to conform to the $35 cap on insulin, which means that you may be charged a higher amount when filling a prescription for insulin during this period. If you pay more than $35 for a month’s supply of a covered insulin product in January and/or February 2023, your plan must refund you within 30 calendar days for any amount that exceeds the $35 cap. To obtain a refund, contact your plan for instructions.
If you take insulin, it is critical to obtain assistance comparing Medicare drug plans and expenses for 2023:
- Dial 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
- Get in touch with your local State Health Insurance Assistance Program (SHIP) to obtain free, personalized health insurance counseling.Please be aware that beginning July 1, 2023, comparable cost caps will apply to insulin used in conventional insulin pumps (which are covered under Medicare Part B).
For insulin used in a traditional insulin pump that is covered by the Medicare durable medical equipment benefit, you will be responsible for 20% of the Medicare-Approved Amount after meeting the Part B deductible. You will be required to pay the full cost of insulin-related supplies (such as syringes, needles, alcohol swabs, and gauze), unless you have Part D coverage.
Note:
To determine the cost of a test, item, or service, consult with your healthcare provider or doctor. The specific amount you will be required to pay may be influenced by several factors, such as the presence of other insurance, the doctor’s fees, whether or not your doctor accepts assignment, the type of facility, and where you receive your test, item, or service.
How will insulin coverage in 2023 impact my coverage?
Can my plan eliminate insulin products from their list of covered medications during the year, or impose restrictions like prior authorization or step therapy?
Your plan may alter their list of covered drugs (formulary) for specific reasons during the year. Your plan may make changes such as:
- Adding or removing medications
- Moving a drug to a lower cost-sharing tier
- Substituting a brand-name drug with a generic version
- Eliminating utilization management requirements
In general, your plan must give you at least 30 days’ notice prior to modifying the cost or coverage of your medication.
Does the $35 monthly cap apply to other types of prescription drugs that I take to manage diabetes besides insulin?
No, the $35 monthly cap only applies to Part D-covered insulin.
If I use a traditional pump to take insulin, will I have to pay the Medicare Part B deductible and will a Medigap supplemental plan cover other costs?
Starting July 1, 2023, the Medicare Part B deductible will no longer apply for insulin used through a traditional pump that is covered under the durable medical equipment benefit. Your Medicare Part B coinsurance for a month’s supply of insulin will not exceed $35. If you have Medigap coverage that pays your Medicare Part B coinsurance, it should cover the cost of insulin, which is $35 or less.
How will my disposable “patch” pump be covered?
If you use an insulin patch pump, your insulin will continue to be covered under Part D, and the cost for the insulin that goes into the pump will not exceed $35 per month. However, the disposable pump itself is considered a supply and not a drug, so the cost of the pump is not capped at $35 under Part D.
How will my costs be affected?
Will I be charged more than $35 if I have Partial Extra Help?
No. If you have Partial Extra Help with your Part D costs, you’ll pay $35 or less for each month’s supply of a covered insulin product. If you have Full Extra Help, you’ll already have lower cost-sharing for insulin and will continue to pay the lower amounts.
Do I have to pay different costs at preferred and non-preferred pharmacies under my drug plan?
No. You’ll pay $35 or less for each month’s supply of a covered insulin product at any in-network pharmacy that’s covered by your drug plan.
Which insulin costs will count towards my True Out-of-Pocket (TrOOP) costs? Will it apply to my Part D deductible?
Your $35 or less copayment for each month’s supply of every insulin product will count towards your TrOOP. Before you meet your Part D deductible, your copayment of $35 or less will be applied to your deductible.
Starting in 2023, any amount you would have paid beyond the $35 cap for a covered insulin product will also count towards your:
- Deductible
- Total true out of pocket (TrOOP) costs
- Progression through the Part D coverage phases.
Can I assume the $35 cap applies throughout all the prescription drug coverage phases under Medicare Part D?
Yes, the $35 cap applies across all phases, including the coverage gap.
Is there a way to estimate when I will progress through the coverage phases in Medicare Part D?
You can add your insulin products to your drug list on your secure Medicare account to compare plans and get accurate estimates of the coverage phases, including the amount you would have paid above the $35 cap, which counts towards the progression through the coverage phases.
Here are Some Ways to Reduce the Insulin Coverage in 2023:
Patients who are struggling to afford their insulin can explore cost reduction strategies. These strategies may include:
- Using a patient assistance program to obtain free or discounted insulin
- Switching to a less expensive form of insulin
- Shopping around for the best insulin price
- Using a prescription drug discount card
- Applying for financial assistance
FAQS about Insulin Coverage in 2023:
Q: Can patients still use patient assistance programs if they have insurance coverage for insulin?
A: Yes, patients can still use patient assistance programs to obtain free or discounted insulin even if they have insurance coverage.
Q: Will the changes in insulin coverage affect patients with private insurance?
A: The changes in insulin coverage will primarily affect Medicare beneficiaries. However, some private insurance plans may also adopt the Senior Savings Model.
Final Word:
The changes in insulin coverage in 2023 are a step in the right direction towards making insulin more accessible and affordable for patients. As the cost of insulin continues to be a major concern, it’s important for policymakers and insurers to work towards long-term solutions that ensure all patients have access to the medication they need to manage their diabetes effectively. Additionally, patients can explore different Part D plans to find the one that covers their insulin needs and ensures they receive the best possible health care.
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
*By completing this form, you agree that an authorized representative or licensed insurance agent may contact you by phone,email,text, mail or face to face to answer your questions or provide additional information about your Medicare plan options. Not affiliated or endorsed by Medicare or any state or federal governmental agency.
