Last updated April 24, 2024
When to use:
Caller has questions about insulin in relation to their Medicare coverage. See medicare.gov > "diabetes" or "insulin" for more.
Diabetic coverage publication:
CMS has issued a new comprehensive Diabetic publication.
New CMS Resource about Insulin and Extra Help:
Other diabetes prescription medication not covered by the $35 per month limit:
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 Inflation Reduction Act's (IRA) cost-sharing cap of $35 for a month's supply of a covered insulin product. These include, but are not limited to, the following drugs:
- Trulicity
- Bydureon BCise
- Byetta
- Mounjaro
- Ozempic
- Symlin
- Victoza
What amounts paid count toward the Medicare 2023 Part D deductible and True Out-of-Pocket costs (TrOOP):
If someone with Medicare fills a prescription for a Part D covered insulin product before meeting the Part D deductible, their cost-sharing amount (up to $35 maximum for a month’s supply) will be applied to their deductible. Under the IRA, a person with Medicare isn’t required to meet the Part D deductible before Medicare will cover a Part D covered insulin product or recommended preventive vaccine, and recommended preventive vaccines have zero cost sharing.
In addition, for plan year 2023, under the IRA, the amount Medicare pays for a covered insulin product or recommended preventive vaccine that would otherwise have been paid by the Medicare enrollee (i.e., if the IRA’s cost sharing caps did not apply) will also count toward the person’s deductible and total true out of pocket (TrOOP) costs, and will count toward the person’s progression into the catastrophic phase of the Part D benefit.
Estimating when a person will move through the coverage phases in Medicare Part D:
In the Medicare Plan Finder, once someone adds their insulin products to their drug list and compares plans, the coverage phase details shown are accurate estimates for moving through the phases. The full cost amount of insulin (more than the $35/month’s supply cap) will be counted toward out-of-pocket costs.
Reimbursement for month's supply more than $35:
For a month’s supply of covered insulin products dispensed between January 1, 2024, and March 31, 2024, a Medicare Part D prescription drug plan must reimburse the person with Medicare within 30 calendar days for any cost-sharing amount the person is charged that exceeds $35. By March 31, 2024, all plans should have their systems updated to process point of sale pharmacy claims so that enrollees aren’t charged more than the maximum $35 cost sharing amount for a month’s supply of each covered insulin product.
How the Inflation Reduction Act (IRA) applies to disposable "patch" pumps:
People with Medicare Part D coverage who use an insulin patch pump (i.e., a small wireless, tubeless pump worn directly on the body, for example Insulet Omnipod) will continue to obtain their insulin through their Part D prescription drug plan benefit. For these people, the $35 cost sharing cap for a month’s supply of each covered insulin product (i.e. the insulin that goes into their pump) applies starting January 1, 2023. The disposable pump itself can be covered under Part D as an insulin supply, but because it is a supply and not a covered insulin product, the cost-sharing for the disposable pump is not subject to the $35 cost-sharing cap, and the plan deductible may apply. Also, because the disposable pump is a supply (and not a drug), people with Medicare cannot add the pump to a drug list in Medicare Plan Finder.
Insulin types removed from drug formulary and what to do:
A number of Medicare Advantage and Medicare Part D plans are dropping some insulins from their formularies in 2025 order to avoid the $35 per month cap. Make sure the insulin(s) the beneficiary is taking will be covered by their plan in 2024 through the review in the Medicare Plan Finder.
Senior LinkAge Line staff should be prepared to assist Medicare beneficiaries with requesting exceptions for their insulin if it is not covered in 2024.
Minnesota insulin safety net program:
https://www.mninsulin.org/
There are two different programs: Urgent Need Program Continuing Need Program
Urgent need program:
Eligible Minnesotans can receive a 30-day supply of insulin immediately at their pharmacy for no more than $35.
To be eligible for this program you must:
- Live in Minnesota.
- Have an urgent need for insulin.
- Have a current prescription for insulin.
- Pay more than $75 each month for your insulin.
- Not be enrolled in Medical Assistance or MinnesotaCare. (but can have Medicare)
- Present identification proving Minnesota residency in the form of a valid Minnesota identification card, driver’s license or permit, or tribal-issued identification.
You can normally access an urgent-need insulin supply only once in a 12-month period. However, if you are waiting for your Medical Assistance or MinnesotaCare coverage to begin, or if you have been determined ineligible for a manufacturer’s patient assistance program by the manufacturer and are waiting for the Minnesota Board of Pharmacy’s decision on an appeal, you may be eligible to access a second 30-day supply.
To Apply: https://www.mninsulin.org/urgent-need/index.jsp
Insulin types removed from drug formulary and what to do:
Eligible Minnesotans can receive up to a year supply of insulin for no more than $50 per 90-day refill.
The continuing need program requires insulin manufacturers to provide insulin to eligible individuals for up to one year, with the option to renew annually. Throughout the year you are determined eligible, the manufacturers will provide your prescribed insulin for a co-pay of no more than $50 for each 90-day supply.
Some individuals with insurance may be referred to a manufacturer’s co-pay program, which waives all or part of the co-pay that the patient normally has to pay, if the co-pay program provides you a better value.
To be eligible for this program you must:
- Live in Minnesota.
- Present identification proving Minnesota residency in the form of a valid Minnesota identification card, driver’s license or permit, or tribal-issued identification. If you don't have one of these but you have an Individual Taxpayer Identification Number (ITIN), you can provide that instead. If you are a minor under the age of 18, your parent or legal guardian must provide the pharmacy with proof of residency or an ITIN.
- If you are a minor under the age of 18, your parent or legal guardian must provide the pharmacy with proof of residency.
- Have a family income that is equal to or less than 400% of the federal poverty guidelines (FPG) income. See the Minnesota Board of Pharmacy website for more information about the FPG guidelines.
- Not be enrolled in Medical Assistance or MinnesotaCare.
- Not be eligible to receive health care through most federally funded programs. Note: An individual who is enrolled in Medicare Part D is eligible for a manufacturer's insulin safety net program if the individual has spent $1,000 on prescription drugs in the current calendar year and meets the other eligibility requirements.
- Not be eligible to receive prescription drug benefits through the Department of Veterans Affairs, but can have Medicare
If you have insurance that covers drugs, you may be eligible to receive insulin on a continuing need basis. However, if you pay $75 or less in out-of-pocket costs for a 30-day supply of insulin, you are not eligible. (Out-of-pocket costs include co-pays, co-insurance and deductibles.)
To apply:
Please see the Patient Information sheet on the Board of Pharmacy website for information and instructions on how to apply. If you need help, contact a MNsure-certified navigator trained to help through the process.