Insulin Coverage Through Medicare Part D

Managing diabetes is challenging enough, but navigating Medicare coverage on top of it can be overwhelming. At the same time, millions of older adults rely on Medicare to help cover the cost of medications, supplies, and treatment. In fact, according to a 2024 report from CMS, an estimated 17 million Medicare beneficiaries are diabetic, while likely 3 million more are undiagnosed. With diabetes being a widespread health condition among older adults, it’s important to understand how Medicare can help cover the costs of managing it.

Out of the nearly 20 million Medicare beneficiaries affected by diabetes, more than 3.3 million depend on insulin. Historically, insulin expenses have been exceedingly high and have been a financial burden to those who depend on this life-saving medication. In this article, our team at Twin City Underwriters breaks down the changes over the past few years and what you can expect now from insulin coverage benefits and Medicare Part D.

What Has Changed with Medicare Part D and Insulin Coverage?

Not that long ago, insulin costs were crippling the wallets of millions of seniors, with many paying hundreds or even thousands of dollars each month for their diabetes medications. At the time, out-of-pocket costs for insulin would fluctuate from month to month, in part due to the different rules applying for each phase of the Part D benefit. With the new insulin coverage rules, fluctuations in prescription costs have been minimized.

Beginning in 2021, the Centers for Medicare and Medicaid announced the insulin savings model for eligible enrollees. One component of the Part D Senior Savings model required Medicare Part D prescription drug plans, as well as Medicare Advantage plans with drug coverage, to offer lower insulin costs on select prescriptions, including a $35 monthly cap on each supply of insulin.

Related: How Does Medicare Part D Work?

How the $35 Insulin Cap Works Under Medicare

Under current Medicare rules, the cost of insulin is capped at $35 per month for each covered prescription. This pricing applies to all Medicare Part D plans and many Medicare Advantage plans that include drug coverage. The $35 cap applies regardless of whether or not individuals have met their annual RX deductible, helping to reduce out-of-pocket costs from the very start. It has been a key part of making insulin more accessible and affordable for everyone enrolled in Medicare, providing peace of mind and financial relief for those who need it most.

Who Qualifies for Lower Insulin Costs?

Anyone enrolled in a Medicare Part D plan or a Medicare Advantage plan with drug coverage qualifies for the $35 monthly insulin cap. There are no health or income requirements; you just need to be enrolled in a Medicare plan that includes insulin coverage and has your prescribed insulin on the plan’s formulary.

How to Enroll in a Plan That Covers Insulin

In order to benefit from Medicare’s insulin cost savings, you'll need to enroll in a Medicare Part D plan or a Medicare Advantage plan that includes drug coverage. Not all plans are the same, so it's important to compare your options carefully to ensure your insulin and other medications are covered.

Our team at Twin City Underwriters can help you compare plans and enroll in one that meets your needs. Get in touch to make sure you're not overpaying for insulin.

Additional Medicare Support for People with Diabetes

Medicare provides benefits for more than just insulin coverage. It also offers additional resources and benefits to help manage diabetes effectively. These include:

• Coverage for diabetic supplies like lancets, test strips, and blood glucose monitors to help track and manage blood sugar levels.
• Coverage for therapeutic continuous glucose monitors (CGMs) for patients who sync their insulin devices with their smartphones.
• Medicare Advantage plans that often include extra benefits like diabetes education programs, access to nutritionists, and transportation to medical appointments.
• Special Medicare plans, such as Chronic Condition Special Needs Plans (C-SNPs), tailored specifically for people with diabetes and other chronic conditions to provide extra support.

Find out more about Medicare’s Coverage of Diabetes Supplies, Services, & Prevention Programs

Understanding your Medicare coverage is an important part of managing your health care and prescriptions confidently and affordably. Whether you need help reviewing your benefits or finding a plan that fits your health needs, our team at Twin City Underwriters is here to support you. Reach out to get clear answers and unbiased recommendations so you can make informed choices about your Medicare health insurance options. 

Sources: Medicare.gov

Part D Senior Savings Model

CMS Diabetes Strategy — Impact Report 2024 

This is an updated blog that was originally published in 2020. 

Choosing a Medicare plan can be difficult. Twin City Underwriters helps Medicare recipients in Minnesota, Wisconsin, North Dakota, South Dakota, Iowa and Florida find the Medicare plan that meets their unique needs. Schedule a one-on-one meeting with one of our Medicare insurance brokers to get your questions answered!

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