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1/17/2025 Things to Know about Medicare Insulin Costs

Not all Medicare patients benefit from the $35 monthly cap for insulin because of specific factors related to their coverage or individual circumstances. Here are some reasons why:

1. ### 1. **Plan Limitations**
2.    – **Medicare Part D:** Not all Part D plans immediately adopted the $35 insulin cap. Patients must enroll in a plan that participates in the Medicare Insulin Savings Program (starting in 2021) or plans aligned with cost-sharing limits under the Inflation Reduction Act (starting in 2023).
3.    – **Part B Coverage for Insulin:** If a patient uses insulin through a pump covered under Medicare Part B’s durable medical equipment (DME), the $35 cap should apply starting in July 2023. However, issues with billing or plan administration may cause delays.
4. **Not Enrolled in a Plan That Includes Insulin Coverage**
5.    – Some patients may not have enrolled in a Part D plan or a Medicare Advantage plan that includes insulin benefits.
6.    – Patients with Original Medicare but no additional Part D coverage or who have incomplete understanding of their benefits may face higher costs.
7. Issues with Plan Administration**
8.    – Billing errors or delays in implementing new cost-sharing policies can result in patients being charged more than $35.
9.    – Pharmacies may not have updated their systems to reflect the capped price.
10.  **Non-Covered Insulin**
11.    – The cap applies only to insulin included in the patient’s Medicare plan formulary. If a prescribed insulin is not covered or is off-formulary, the $35 cap may not apply.
12. **Coverage Gaps or Restrictions**
13.    – Patients in coverage gaps or who have restrictions such as prior authorizations for certain insulin products may experience delays or increased costs until those issues are resolved.
14.  **Late Adoption or Implementation Errors**
15.    – The Inflation Reduction Act required changes effective January 2023 (for Part D) and July 2023 (for Part B), but transitional issues could delay benefits for some patients.
16. What Can Be Done?
17. – **Verify Coverage:** Patients should check with their Medicare plan to ensure their insulin is covered and the $35 cap is being applied.
18. – **Review Formularies:** Ensuring their prescribed insulin is on the plan formulary can prevent surprises.
19. – **Seek Assistance:** Medicare’s helpline (1-800-MEDICARE) or local SHIP (State Health Insurance Assistance Program) counselors can provide guidance.
20. – **Pharmacy Advocacy:** Pharmacies can reprocess claims or verify that the $35 limit is being applied correctly.
21. Medicare beneficiaries should contact their plan administrators to resolve discrepancies and ensure they are paying the correct amount.