Some good news for diabetics - $35 copay

On March 11, 2020, CMS announced a new Model that should greatly reduce the cost of Insulin for Medicare Beneficiaries.

We are very excited about this announcement!

Each year during the Annual Enrollment Period, we review thousands of Part D drug lists for our clients.  For those that are taking insulin, Part D out of pocket costs can be very expensive; generally ~$2,000 or more. 

This new Part D Savings Model (which will take effect in 2021) will allow Manufacturers and Part D Plans to offer a flat monthly copay of $35 (or less) for the entire year.    

​For beneficiaries that enroll in these Plans for 2021, we are projecting an annual savings of $700+ for their Out-of-Pocket Insulin Costs.

The Part D Out of Pocket costs can be very confusing.  We created this short video to try to explain the different phases of Medicare Part D, and I will try to summarize below as well.

For this new Part D Savings Model, there will be certain plans that cover certain medications (e.g. Insulin) that will have additional coverage throughout the year, thus keeping a flat copay of $35/month or less.

Current Model Out of Pocket Costs Illustrative Example with One Insulin with retail cost of $435/month
- January = $435 (deductible)
- February through September = $50/month copay during Initial Coverage Level
- October = ~$80 copay (partial month of Coverage Gap)
- November = ~$109 (25% of full retail cost while in Coverage Gap)
- December = ~$109 (25% of full retail cost while in Coverage Gap)
Total ~ $1,135 annual cost

New Part D Savings Model Out of Pocket Costs Illustrative Example with One Insulin with retail cost of $435/month
- January - December = $35/month copay
Total ~ $420 annual cost

Projected Annual Savings ~$700

CMS held a public webinar on Thursday, March 12, 2020.  One of my concerns from this presentation is that this new Model is Voluntary for the Part D Plans and the Drug Manufacturers.  Most of the cost savings (about $250 Million in projected savings) is coming from the Drug Manufacturer, so my concern was that the Drug Manufacturers wouldn't participate since this is a voluntary model.

However, I was excited to find an article from Lilly indicating their planned participation in the model for 2021.  This is really great news for Medicare beneficiaries and we look forward to seeing the Savings when we run the Part D reports in October 2020 for the 2021 Part D Plans.

Finally some good news for Diabetics taking Insulin!

Image from CMS Presentation on March 12, 2020