Cap on Insulin for Medicare Beneficiaries

By Eileen Doherty, MS ~

Denver, CO.  According to the Centers for Disease Control, the sixth leading cause of death is diabetes among individuals age 65 and over.  Type 1 diabetes means the body does not produce insulin, while Type 2 diabetes means the body is processing insulin incorrectly.  Twenty percent of people over age 65 have diabetes.

The Center for Medicare and Medicaid Services has launched the Senior Savings Model, a new program to limit out-of-pocket costs for insulin.  Insulin can cost thousands of dollars per year for many individuals.  Even individuals who have Medicare Part D plans often face high costs as insulin can be a Tier 4, 5 or 6 drug resulting in Medicare beneficiaries often paying 50% of the cost of the drug out-of-pocket.

Participation in the Senior Savings Model is voluntary by the prescription drug plans and the Medicare Advantage companies; thus, not all plans offer the $35 per vial co-payment in Colorado. 

Most prescription drug plans in Colorado follow the standard prescription drug benefit.  As such the first $445 of retail cost of prescriptions is paid by the beneficiary.  The beneficiary then pays 25% or about $2500 of the next $10,178 retail charges for prescriptions through the donut hole.  When the retail costs of prescription drugs exceed $10,178 and the individual reaches catastrophic coverage, the individual then will be responsible for paying $3.70 for generic drugs costing less than $74 or 5% of the cost of the drug costing more than $74.  For brand-name drugs in the catastrophic coverage, the beneficiary will pay $9.20 for drugs with a retail cost under $184 or 5% of the cost of drugs costing more than $184.

If a beneficiary needs only one vial of long-acting and one vial of short-acting each month, the beneficiary should see significant savings and only have to pay $35 for the long-acting and $35 for short-acting insulin per month.  However, if a beneficiary needs two vials of each, the monthly retail cost may be significantly higher depending on the tier, the quantity limits, and other co-pays.

Use the plan finder at www.medicare.gov to review your estimated out-of-pocket costs, based on your insulin needs to realize as much savings as possible.

Medicare Part B also pays for diabetic supplies such as lancets and test strips that are purchased at a Medicare Part B participating provider.  While beneficiaries may be able to purchase supplies at a pharmacy in a grocery store, that pharmacy may not be a Medicare Part B participating provider.

November is American Diabetes month. While diabetes is preventable, treatment includes physical activity, a healthy diet, and weight control. 

For information on risk factors, prevention, and ways to manage diabetes, visit us at www.senioranswers.org or call 303-333-3482.

Eileen Doherty

Eileen Doherty, MS is the Executive Director of the Colorado Gerontological Society.  Her areas of expertise include management and administration of nonprofit organizations, education and training on issues related to older adults, advocacy and policy development on senior issues, and clinical practice in working with seniors and families to manage their lives in the later years. She has been the Director of the Society since 1982.  She teaches Nonprofit Management for anthony@lafifty.com