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Medicare’s $35 Insulin Copay Deal Could Be Tricky to Get

Glitch on the program’s website means consumers likely will need help picking best Part D plan

Insulin is displayed at Pucci's Pharmacy in Sacramento, Calif., July 8, 2022. The recent passage of legislation that would limit the cost of insulin for Medicare patients has renewed hope for advocates pushing for Congress to do more.
Rich Pedroncelli/AP Newsroom

As Medicare beneficiaries look at their options for 2023 during this fall’s open enrollment period, enrollees who need insulin to help control their diabetes will find they have a great new benefit — but they might also need some help finding the best and most affordable prescription drug plan.

The good news: Starting in 2023, the Inflation Reduction Act, signed into law in August, caps insulin users’ out-of-pocket costs at $35 per month for each insulin product covered by their Medicare Part D prescription drug plan or their Medicare Advantage plan.

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The challenge: The cap was enacted after insurers set their premiums and copays for 2023. So the Medicare Plan Finder — the primary tool beneficiaries use to review and select Part D and Advantage plans — doesn’t include that $35-a-month cap in its estimates of a beneficiary’s annual drug costs.

The result: Confusion. The cap applies only to insulin products on a plan’s list of covered medications, called a formulary. Most drug plans don’t cover all of the more than 70 insulin products on the market. And some plans actually charge less than $35 a month for particular products, but those lower copays are difficult to ferret out on the Medicare Plan Finder. Adding to the complexity of making a choice of plans, many diabetics use several prescription drugs besides insulin.

So, finding the lowest-cost, most effective plan that covers all an enrollee’s medicines among the 20 or more plans that might be offered in someone’s zip code could be mind-numbingly complicated, at least for 2023.

How to cope? Determined do-it-yourselfers might be tempted to winnow the options on their own.

But Medicare officials and the local offices that support beneficiaries have a different message: Get help. “People with Medicare who take insulin are encouraged to call 1-800-MEDICARE or to contact their State Health Insurance Assistance Programs (SHIP) for help comparing coverage and costs this year,” Meena Seshamani, M.D., director of CMS’s Center for Medicare, said in an emailed statement. This is just a one-year glitch, the Centers for Medicare & Medicare Services says, so it’s best handled by those with practice navigating the Plan Finder.

Why did this glitch happen?

Congress enacted the cap on insulin cost-sharing in response to diabetics’ struggles to afford the lifesaving hormone that they depend upon every day to control their blood sugar. CMS estimates that the cap “will benefit at least 1.4 million people with Medicare.” The Inflation Reduction Act also includes other measures to reduce drug costs and out-of-pocket Medicare expenses.

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But the new law didn’t get to the president’s desk until long past the June 6 deadline for insurers to submit their bids for 2023 Part D and Medicare Advantage plans. Those bids and their cost-sharing arrangements were locked in, and they “cannot be modified after the bid process concludes for the year,” CMS’s Seshamani explains. “Because the Medicare Plan Finder can display only what is in the [bids], the insulin cost sharing can’t be updated on the Plan Finder” for 2023 plans.

Recognizing the difficulties this could create for diabetics, CMS has stepped up its public messaging and peppered the Plan Finder with notices. For example once a beneficiary adds NovoLog — a popular insulin — to their drug list, an alert appears, explaining the new cap and warning: “You should talk to someone for help comparing plans.” The alert links to resources, including 1-800-MEDICARE and the SHIP program, which recruits and trains local volunteers to help  beneficiaries cope with Medicare’s complexities.

The added work is putting a strain on SHIP programs, says Kelli Jo Greiner, Minnesota’s SHIP director and a member of the national SHIP Steering Committee. “We’re all getting a lot of questions, and using the Plan Finder [for insulin users] is taking counselors a lot more time,” Greiner says. “All of us are thrilled to see this change, because insulin is such an expensive medication.” But the failure to update the Medicare Plan Finder “did throw a wrench into our ability to counsel people effectively,” she says.

Beneficiaries need to be aware that most Part D and Medicare Advantage plans cover only certain insulin products, Greiner notes. She also points out that other drugs that diabetics use to increase insulin’s effectiveness — often expensive brand-name drugs — are not subject to the $35-a-month cap. “We’re communicating as much as we can,” she says.

How can you cope?

Some insulin users still might be tempted to tackle the Medicare Plan Finder themselves. The experts say: Don’t.

Figuring out the best Part D or Medicare Advantage plan for an insulin user requires going through the Medicare Plan Finder several times and comparing a number of details within multiple plans. Keeping track of the numbers can require creating a spreadsheet. “People who try to use the Plan Finder themselves could end up very confused,” says Greiner.

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Instead, the experts suggest you make a list of all your prescriptions, including the dosages and how often you refill them. If you don’t already have an online account on Medicare.gov, go there and create one — it allows you to store your drug list securely, which can speed up the task of finding a plan.

Then you have two choices:  

  • Call 1-800-MEDICARE and seek help there, or
  • Go the SHIP website to look up the agency that administers SHIP in your state.

Then call the state agency to find the county or other local office, and get hooked up with a trained counselor who can analyze plans for you.“SHIPs [provide]objective, comprehensive, unbiased information on Medicare — we aren’t marketing any plans,” Greiner says. The counselor will make sure, for example, that any Medicare Advantage plan you consider actually covers the insulin products you need.