Insulin - as well as most self-administered medications - is covered under Medicare Part D.
Insulin is a necessary medication for over 10 million Americans with diabetes. All Medicare Part D plans – whether standalone or prescription drug coverage included with a Medicare Advantage plan – must include insulin in their drug formularies. Although Original Medicare provides excellent benefits, its coverage does not include prescription drugs.
What are insulin pens?
Insulin pens are medical devices used to inject insulin. There are other products that do this as well, such as insulin pumps. In most cases, insulin devices and insulin medication will be covered separately. As a result, some plans may cover insulin, but not insulin pens. This article will describe the coverage options for both insulin and insulin pens under every part of Medicare.
Does Medicare Part A cover insulin pens?
Medicare Part A is often referred to as hospital insurance because it covers inpatient care. Although usually associated with hospital care, Part A also pays for skilled nursing facility care, hospice care, and home health care in limited cases.
Medicare Part A does not cover insulin pens. However, if you receive insulin while you are an inpatient in a hospital, it will be covered by Part A. There may be some exceptions to this rule, so it is best to discuss insulin coverage with your inpatient healthcare provider.
How much insulin coverage does Part B provide?
Medicare Part B covers outpatient care. This includes most procedures, tests, and check-ups that you may undergo in a doctor’s office. Like Part A, Part B does not cover insulin, with the exception of insulin pumps, which are discussed below.
Part B covers durable medical equipment, also known as DME. It includes equipment like wheelchairs and other mobility aids, as well oxygen tanks. Medicare only covers durable medical equipment that is considered medically necessary for your condition. DME can be purchased or rented.
Part B covers some equipment used by people with diabetes as DME. This includes blood sugar monitors, continuous glucose monitors, therapeutic shoes, lancet devices, blood glucose test strips, and insulin pumps. However, insulin pens are not covered.
Insulin pumps can be covered as DME, in which case the insulin is covered as well. This is the only scenario in which Medicare Part B will provide coverage for insulin.
If you receive DME under Part B, make sure to only go through a Medicare-approved DME supplier. Otherwise, you'll likely be responsible for 100% of the cost. You may also need to receive prior authorization for durable medical equipment.
Medicare Advantage coverage for insulin pens
Insulin pen coverage under Medicare Advantage is available, but can vary. Also known as Part C, Medicare Advantage is sold by private insurance companies, but is regulated by the federal government. It is an alternative to Original Medicare, rather than an additional part.
Medicare Advantage insurance plans are required by law to cover at least the same things as Original Medicare. However, Medicare Advantage plans can also cover more than Original Medicare does. This comes in two forms. One of these is additional perks like fitness plans, as well as dental or vision care.
The other is prescription drug coverage, which some Part C plans bundle with their main healthcare coverage. These Medicare Advantage prescription drug plans (MA-PD) offer full drug coverage, and you cannot purchase a Part D prescription drug plan if you have one. These plans cover insulin, but the amount that you pay out-of-pocket can vary a lot.
Because you can’t purchase another drug plan if you go the MA-PD route, make sure that the plan you choose has all of your bases covered. You may find a plan that has drug coverage that works for you, but has other downsides such as a limited provider network. Make sure to look at each plan in detail, or get help from an independent insurance agent.
MA-PD plans may cover insulin pens in some cases, but it is not guaranteed.
Insulin pen coverage from Medicare Part D prescription drug plans
Part D plans are the most common go-to way of getting insulin coverage. Like Part C plans, Part D plans are sold by private insurance companies. This means that the costs and exact coverage details will vary depending on which plan you choose. Part D only covers prescription drugs, and over 70% of people enrolled in Medicare have a Part D plan. There are many plans on the market for you to compare.
Each Part D plan will have its own formulary that splits drugs into tiers. A drug tier is a level that tells you how much coverage applies to that drug and how much you will have to pay in co-payments or co-insurance for it. When you compare Part D plans, looking at the formulary is the way to find out how expensive insulin will be under that plan.
Each Part D plan may have a different coverage model for other supplies. There are some Part D plans that cover supplies like monitors and alcohol swabs, and some may cover insulin pens as well. However, you shouldn’t assume that a given plan does without confirming.
What is the insulin savings model?
As of 2021, there is a new program that applies to both Medicare Advantage plans and Part D plans known as the insulin savings model. This model allows you to compare plans that cover insulin at a cheaper cost more easily.
Participating plans will cover a 30-day supply of insulin for no more than $35. There will be other factors you need to look into to determine whether these plans are a good fit for you, so it is still a good idea to compare quotes and examine the formulary in more detail.
Medicare.gov provides a tool that allows you to compare plans and see which ones provide this type of coverage.
Can I get insulin covered through Extra Help?
Extra Help is a Medicare program that provides additional assistance with drug coverage for people with a limited income. There are several ways to qualify, as well as multiple levels of coverage.
Extra Help can decrease how much you pay for insulin. If you receive full Extra Help, then you will pay less than $35 per month for insulin. Those who receive partial Extra Help will have to pay a yearly deductible of no more than $92. After meeting the deductible, they'll have a 15% co-insurance for insulin coverage. The amounts can vary depending on which level of Extra Help you qualify for.
You can contact Medicare at 1-800-MEDICARE if you need to find out which level of extra help you qualify for.
Key things to remember about Medicare and insulin coverage
If you need insulin, make sure that you understand your options before your Medicare benefits begin, so you don’t experience a gap in coverage.
When you compare plans, always go to the formulary if you want to compare out-of-pocket insulin costs. This way, you can see exactly what you will pay for insulin under each plan and can see how that coverage fits into the plan’s overall offerings.
You should also not forget to compare plans that are part of the insulin savings model. Because this is new, it may be easy to overlook. With these participating plans, you should still make sure to get a more general overview so that you can understand what the plan covers at every level.
Lastly, keep in mind that although you have several insulin options available, insulin pen coverage is not available under Medicare.
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