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Original Medicare Parts A and B do not typically cover the cost of insulin.
The only exception to this is if your doctor determines that an insulin pump is medically necessary.
If you need insulin coverage you will need to enroll in Medicare Part D or a Medicare Advantage plan that includes prescription drug benefits.
Insulin is a vital part of diabetes management for many seniors. As with any prescription medication that must be taken regularly, it’s important to know how insurance plans, like Medicare, cover insulin. This article discusses how insulin and other related supplies are covered under Medicare and Medicare Advantage plans.
Let us help you make sure you get the prescription drug coverage you need. Call (800) 950-0608 for live assistance form a licensed agent.
Under Original Medicare Parts A and B insulin is not covered. You are required to pay 100% of the cost for insulin and insulin pens, in addition to related insulin supplies such as alcohol swabs, insulin needles, syringes, and gauze.
The reason that Original Medicare does not cover insulin and supplies related to its administration is that prescription drugs does not fall under the services covered by hospital insurance or medical insurance, which are the areas Part A and Part B deal with respectively.
Instead, seniors who wish to receive coverage for prescription medications like insulin must enroll in Medicare Part D, also known as a Medicare prescription drug plan, or they must enroll in a Medicare Advantage plan that includes prescription drug benefits.
Medicare Part D is the part of Medicare that covers most prescription drugs outside of a hospital setting. If you are enrolled in Original Medicare, it is available as a separate plan. For those who are enrolled in Medicare Advantage, Part D coverage can be included within your plan. All Part D policies are required to cover at least two drugs from the most commonly prescribed categories and protected drug classes in this list:
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As of January 1, 2021, Medicare has introduced a Part D Senior Savings Model. Part D plans that are part of this model will only charge a $35 copay for insulin. But this particular benefit is only available with enhanced Medicare Part D plans and Medicare Advantage Prescription Drug plans (MAPD). In 2021 alone, 1,635 Part D and Medicare Advantage plans and over 75 insurance carriers committed to participate. They cover a variety of medications, sometimes with a higher deductible. Insulin medication is not subject to annual deductibles, initial coverage, or coverage gap phases of drug coverage. The catastrophic phase, however, is unaffected.
Seniors who are not enrolled in a savings model plan will see a reduced cost for their insulin once they reach the yearly $6,550 in out-of-pocket costs for prescription drugs. After this limit is reached, beneficiaries reach the catastrophic coverage phase where their costs for prescription drugs are greatly reduced. Here the cost of insulin paid is whichever cost is highest between paying 5% of its price, or $3.70 for generics and $9.20 for brand-name medications.
Understanding how Medicare Part D plans work is not easy, and it can be confusing, especially with the new changes taking effect in 2021. If you need help finding a Medicare Part D plan that fits your needs, call us at (800) 950-0608. We’ll be happy to help you find coverage that fits your needs.