Insulin costs always seem to rise, which is a significant problem for many Medicare beneficiaries. These high prescription costs affect more than 3 million seniors. For many going without this necessary medication isn’t an option. Failure to use it correctly can cause serious health concerns.

In January 2021, the Trump administration set forth an initiative called the Part D Senior Savings Model. The program was introduced to create lower costs and increase the affordability of insulin.

What is the Medicare Part D Senior Savings Model?

The Part D Senior Savings Model was enacted to help limit the amount beneficiaries can pay for their insulin costs.

This model allows Medicare Part D prescription drug coverage to limit the expense of insulin to $35 throughout all coverage stages of the Medicare prescription drug plans.

Diabetes.org states that almost 27% of individuals over 65 have diabetes. This is why lowering the costs of insulin is so important.

Many Medicare beneficiaries have a hard time making ends meet. Some even face the challenge of paying for the medications they need to stay alive and their meals.

How The Part D Senior Savings Model Works

Because of the Part D Senior Savings Model, Medicare beneficiaries will have more choices when it comes to insulin. It’ll also limit the costs of a 30-day supply to no more than a $35 copay on select insulins. This cap is effective no matter what coverage phase the beneficiary is in.

Since this is a voluntary program, not all Part D plan sponsors or drug manufacturers participate. Several plan options will be available that participate in the Part D Senior Savings Model.

The Centers for Medicare and Medicaid Services estimate that the average savings a Medicare beneficiary should experience is just under $500.

What Medicare Plans participate in the Part D Senior Savings Model?

The Part D Savings Model will apply to Medicare Advantage plans and standalone Part D coverage that participate. When enrolling in a participating program, you can expect to pay no more than $35 for your monthly supply of insulin.

Remember, every plan covers not all insulins, so ensure that your plans’ formulary insulins include the one you’re taking. Part D plans are standalone prescription drug coverage and have monthly premiums. These plans are usually combined with Original Medicare or a Medicare Supplement.

Medicare Part C

Medicare Advantage plans will combine your Medicare Part A and Part B. In most cases, your Part D benefits will also be included.

These programs are also called MAPD plans. Enrollment into an MAPD plan will have cost-sharing for your coverage dictated by the plan’s schedule of benefits, not the out-of-pocket costs outlined by Orignal Medicare.

If you’re taking a type of insulin from a drug manufacturer that isn’t covered, consult your healthcare provider to see if you can change to another insulin that’s participating. Part D sponsors can offer additional coverage gap discounts but often don’t.

They choose not to because it would lower the amount that the drug manufacturers are required to pay for beneficiaries in the Donut Hole.

Medicare Part D

Medicare PDPs consist of four coverage stages. Regardless of if you’re in your Deductible, Initial Coverage, or Coverage Gap stages. Suppose you’re taking a participating Insulin and enrolled in a participating plan.

In that case, you’ll pay no more than a $35 copay for one month’s supply of insulin. This results in more predictable costs for your insulin.

Without the model, if you were in the coverage gap phase, you’d be responsible for 25% of the cost of the insulin. In the catastrophic phase, you’ll pay 5% of the cost of a small copay, whichever is greater. The Medicare Part D Senior Savings Model now doesn’t affect the catastrophic phase.

Studies have initially shown that the average cost of Part D drug plan sponsors participating in the Senior Savings Model has higher premiums. In contrast, the average price of participating MAPD plans has decreased the monthly premiums.

Medicare Advantage plans vary depending on the area. Speak with a licensed insurance broker to find a Medicare Advantage plan that participates in the Part D Senior Savings Model.

Participating Part D Sponsors and Manufacturers

The following pharmaceutical manufacturers are participating in the Part D Senior Savings Model for 2022. Keep in mind this could change in 2023.

  • Eli Lilly and Company
  • MannKind Corporation
  • Mylan Specialty L.P., a Viatris Company
  • Novo Nordisk, Inc., and Novo Nordisk Pharma, Inc.
  • Sanofi-Aventis U.S. LLC

The Plan D plans that are participating in the Part D Senior Savings Model include:

What happens when someone can’t afford to pay for their insulin and doesn’t take it?

When someone has insulin-dependent diabetes but doesn’t take their insulin as directed, a slew of health issues could be triggered. Most of these situations will create life-threatening health outcomes such as heart attacks and strokes. In addition, not taking the proper dosages can result in hypertension and high cholesterol, leading to heart disease.

When individuals have poor health, these adverse reactions to not taking their required medications can result in death. Prescription Medications are vital to the ongoing health maintenance of most Medicare beneficiaries.

Programs that Assist in Paying Prescription Drug Costs

If you’re having problems paying for your prescription drugs, a few programs are available to help. The Extra Help or Low-Income Subsidy is a federal program that helps beneficiaries with low-income pay for their Medicare Part D premiums and prescription costs.

Another program that can help is to contact your local ship office to see if you qualify for the State Pharmaceutical Assistance Program (SPAP). An SPAP is a state-run program to assist with prescription medication costs.

FAQs

What is the Part D Senior Savings Model?

The Medicare Part D Senior Savings Model is a program initiated by the Trump administration in January of 2021. It lowers the cost of select insulins for beneficiaries enrolled in participating Part D or MAPD plans.

This program is scheduled to run through December 31, 2025. 2,159 Medicare plans, including drug coverage, currently participating in the program.

Which Part D plans have $35 insulin?

Not all prescription drug plans participate in the program. Nationwide Part D plans that participate in the Part D Senior Savings Model include:

When did the Part D Senior Savings Model start?

The voluntary Part D Senior Savings Model began on January 1, 2021.

Who qualifies for the insulin savings program?

Any Medicare beneficiary that enrolls in a participating Medicare Part D plan or MAPD qualifies for the program. Your insulin manufacturer and plan must be participating for the savings to occur. If your insulin manufacturer doesn’t participate, speak to your doctor. There may be another insulin you can take from a company that’s included.

What is the maximum you can save?

There isn’t a prediction on the maximum, but the estimation is on average, Medicare beneficiaries will save almost $500 per year. Keep in mind that this is a projected average.

Individual savings could be more or less dependent on several factors. Factors include the type of insulin and what coverage you have for your medications.

What is the maximum annual drug cost for a senior?

Medicare prescription drug costs don’t have a cap. You’ll have expenses every time you pick up prescriptions unless you have a plan with a $0 copay for your drugs or prescription assistance from extra help, Medicare, or another related assistance program.

How much does it cost?

Suppose you’re enrolled in a plan that participates in the Medicare Part D Senior Savings Model. In that case, You can expect to pay no more than $35 for a month’s supply of insulin.

This applies to participating plans, pharmaceutical manufacturers, and select insulins. The coverage will be the same through the deductible, initial coverage, and coverage gap phases.

What is the name of the program?

The insulin savings program is the Part D Senior Savings Model. The Trump administration initiated it in January 2021. This voluntary program lowers the cost of select insulins for beneficiaries enrolled in specific participating plans.

How to Get Help with the Senior Savings Model

When it comes to deciphering which plan fits your needs, it can be daunting. There are many options to choose from, and the benefits can vary. Working with one of our licensed insurance agents can ensure that you enroll in a plan that is best suited to cover your medical costs.

Our agents can use their online plan finder and cross-reference with Medicare.gov to ensure the plan will fit your needs and lower costs. Call us at the phone number above, or fill out our online request form. We can’t wait to help!

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by Lindsay Malzone, Lindsay Malzone is the Medicare editor for Medigap.com. She's been contributing to many well-known publications since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.