Updated 3rd-August-2020

Under recently announced plans, Seniors enrolled in Medicare can choose policies that limit co-pays for insulin.  President Trump endorses a deal designed to benefit a significant group of US citizens.

Who is eligible for this plan to cap insulin prices?

Anyone aged 65+, or who turns 65, before the end of March 2021 and who suffers from diabetes (types 1 or 2)


Approximately 25% of seniors (14.3 million people) have diabetes. And not they all are enrolled in Medicare, and of those who are, only 60% are enrolled in a Medicare Advantage plan (Medicare Part D).

Check our article on: How to signup for Medicare at the age 65?

The price of insulin is a great worry to the 30+ million Americans who have diabetes.  Most depend on insulin to maintain their blood sugars at normal levels and to protect them from heart disease and kidney failure.

Most recently, the Coronavirus pandemic is concerning to people with diabetes. While they aren’t any more likely to be infected by COVID-19 than others, the evidence shows that they are more likely to suffer worse outcomes.

Read our article on: Do Medicare plans cover Coronavirus treatments & costs?

https://www.policymed.com/2020/07/trump-signs-four-executive-orders- aimed-at-lowering-drug-prices.html
Trump Signs Four Executive Orders Aimed at Lowering Drug Prices 

In support of his earlier insulin price cap, President Trump has issued an Executive Order to ensure fair pricing for Insulin and Epinephrine. This EO makes it possible for Americans without access to affordable insulin and injectable epinephrine through commercial insurance or Federal programs, such as Medicare and Medicaid, to purchase these pharmaceuticals from an FQHC at steeply discounted prices.

If you are a member of a group plan (employer-sponsored), you will be automatically enrolled in Medicare when you turn 65.  You must ensure that your new policies meet your specific needs. Contact your company’s plan coordinator.

If you are on Medicare:

You MUST add a Medicare Part D supplement that SPECIFICALLY includes the Insulin Price Cap feature.

According to Ms. Seema Verma, Head of Centers for Medicare and Medicaid Services, “There are 1750 plans that offer prescription drug coverage to Medicare recipients and participate in the ‘enhanced’ plans providing supplemental (insulin) benefits.” 

Ms. Verma also noted that plans offering the insulin cap would have more expensive premiums, costing about $17 more per month, per person, than the average cost of basic plans.

“In exchange for a minimal premium increase, beneficiaries get a maximum fixed $35 co-pay for a month’s supply of insulin,” Ultimately the intent is for seniors to save 66% on their insulin costs.

Please don’t leave it to chance. Look into your Medicare supplement options (Part D) now!

What to expect from this insulin price cap plan?

Enrollees who choose drug plans which offer the new benefit will pay a maximum co-pay of $35 per month for their insulin.  There may be a small increase in the monthly premium, but the net saving is estimated to be worth between $400-$500 each year.

By choosing the new supplemental insurance plans, beneficiaries will save money and have the security of a fixed budget to avoid the unpredictable fluctuations in drug prices. At list prices, insulin treatment can cost as much as $5,000 per year. Although insured patients do not pay that much, they are subject to co-pays, which rise when the prices increase. We all know anecdotal evidence that individuals, unable to afford their prescribed doses of insulin, may try to get by with reducing their dosage, a dangerous and sometimes fatal choice!

When will the new benefit of the plan to cap insulin prices come into effect?

The new benefit goes into effect on January 1st, 2021. That seems a long way off, BUT you will need to make sure that your plan for 2021 covers your needs.  You must enroll in your new Medicare Supplement plan during OPEN ENROLLMENT, which begins November 1st, 2020. 

Essential Details about Medicare Part D Insulin benefits: (From Medicare.gov)

Part D may cover these:

  • Insulin
  • Certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs

However, if you use an external insulin pump, insulin and the pump may be covered as durable medical equipment (DME) under Part B. If you live in certain areas of the country, you may have to use specific pump suppliers for Medicare to pay for an insulin pump.

Open Enrollment isn’t far off!  Contact your exchange to review your options.

How to proceed?

It would be best if you were sure that your provider is a participant in the Insulin price cap program and that your specific insulin needs are covered. (Including pens and vials for the formulations; rapid-acting, short-acting, intermediate-acting, and long-acting versions, etc.)

Remember, not all insurers, and not all plans will include the insulin price cap. And not all plans will provide all your prescribed medications on their formulary.

Talk to your exchange and review your coverage.  You may find a change of metal band, say from silver to gold, will now give you better value for money.  You may also benefit from the peace of mind offered by a 5-Star rated provider.  Perhaps your savings could help you cover VisionDental, or possible future Medical expenses.

Make the most of this opportunity!

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