What to know about older adults on insulin under Medicare 

 

Photo by Nataliya Vaitkevich via pexels.

The Inflation Reduction Act, which went into effect on Jan. 1, boasts several health-related provisions that benefit older adults. Among them: lowering the cost of insulin to a maximum of $35 per month.

That’s excellent news for the nearly 16 million people over 65 who have diabetes and use, or may need, insulin to maintain their glucose levels. Insulin prices have skyrocketed over the past few years, causing extensive financial hardship, missed doses, and in some cases, even death due to lack of affordability. The Inflation Reduction Act fixed that, at least for older adults. (Republicans quashed a proposal to extend the cap to everyone who uses insulin). Journalists can use this opportunity to educate their audience about the change in pricing and dispel any myths or misconceptions about the law.

Diabetes is an increasingly serious problem in older people — about one-third of those over 65 have the disease, according to the Endocrine Society. Experts project prevalence to increase significantly in the coming years. Rates of diabetes are even higher among Hispanic, Black, and American Indian/Alaska native populations.

Older adults comprise about half of the newly diagnosed cases of type 1 diabetes each year. Additionally, about 25% of those with type 2 diabetes require insulin, which has seen a price jump of more than 300% over the past decade. Untreated or poorly treated diabetes can lead to serious complications, including cardiovascular and kidney disease, neuropathy, blindness, increased risk of falls, cognitive decline, and premature death. So this price cap is vital for many seniors.

Here’s what to know about the new pricing structure:

  • Medicare drug plans can’t charge beneficiaries more than $35 for a one-month supply of each Part-D covered insulin product, and there is no deductible.
  • That $35/month pricing holds for those who get several months’ supply at a time 
  • Users of disposable insulin patch pumps will continue to get their insulin through their Part D plan, with the insulin cost capped at $35 per month. If a Part D plan covers disposable insulin patch pumps, the pump is considered an insulin supply, but because it isn’t an insulin product, the pump isn’t subject to the $35 cap so might cost more than $35. 
  • The $35 cap on insulin costs starts July 1 for those using a traditional insulin pump covered under Medicare Part B’s durable medical equipment benefit. The Part B deductible will not apply. If a Medigap plan pays Part B coinsurance, that plan should cover the $35 (or less) cost of insulin.
  • Part D plans have until March 31 to update their systems to make sure beneficiaries are charged the correct amount. Meantime, a Medicare Part D prescription drug plan must reimburse a beneficiary within 30 calendar days for any cost-sharing amount the person is charged that is more than $35 for each month’s supply of a covered Part D insulin product. If the enrollee hasn’t received reimbursement within 30 days, they should contact their plan. 
  • CMS will allow anyone who uses a covered insulin product to make a one-time switch to a different Part D plan for 2023 between now and December 31. 
  • The insulin cost-sharing amounts will be updated as part of the next annual Medicare plan finder in fall 2023. In the meantime, beneficiaries are encouraged to contact their plan directly to make sure their product is covered under the new pricing guidelines. 
  • Prescription drugs, including injectable drugs that aren’t insulin products or combination products that combine an insulin product with another drug (e.g., a diabetes management drug), aren’t covered by the prescription drug law’s cost-sharing cap of $35 for a month’s supply of a covered insulin product, according to CMS.

Another benefit effective this year is the elimination of cost-sharing for recommended vaccines like Shingles. More IRA-related cost-savings for Medicare beneficiaries will occur over the next several years, including a $2,000 cap on out-of-pocket spending in 2025, negotiating the prices of the highest-cost drugs starting in 2026, and expanding the subsidy program for low-income beneficiaries (2024).

Resources

2 thoughts on “What to know about older adults on insulin under Medicare 

  1. Avatar photoFeuer Nursing Review

    Awesome article and the information shared by the author is really helpful for everyone. Medicare enrollees now have a $35 monthly cap on insulin. Senior citizens and other Medicare enrollees can now get a break on the cost of their insulin. They won’t pay more than $35 a month for each insulin prescription that’s covered by their Medicare Part D plan. And they won’t be subject to a deductible for insulin.

Leave a Reply