Medicare and insulin cap
The Inflation Reduction Act established a $35 monthly cap on insulin costs for Medicare beneficiaries, effective in 2023. To get access to insulin at this price point, a person must be enrolled in Medicare.
Medicare eligibility usually begins at age 65. However, a person can be eligible earlier if they receive Social Security Disability Insurance (SSDI), or if they live with either end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
Plus, a person’s insulin prescription must be written by a Medicare-participating physician and deemed medically necessary, such as when a person lives with diabetes.
In Medicare, individuals can obtain $35 insulin through Medicare Part D, a Medicare Advantage Prescription Drug (MAPD) plan, or, in certain instances, under Medicare Part B.
Part D is a separate private drug coverage plan that a person can join along with Original Medicare (parts A and B). On the other hand, MAPD is a Medicare Advantage (Part C) plan that combines Original Medicare benefits with prescription drug coverage into a single private plan, eliminating the need for Medicare Part D.
In all cases, there is no requirement to meet the plan’s deductible to access insulin at this price.
Medicare Part D and MAPD allow a person to get any insulin for no more than $35 through various delivery methods:
However, if a person requires the use of an insulin pump classified as durable medical equipment (DME), Medicare Part B will cover both the pump itself and the insulin used within it instead.
Since all Medicare Part C plans (whether or not they are MAPD plans) also incorporate Part B benefits, they will similarly cover DME insulin pumps and necessary insulin.
A 2020 price analysis revealed that the average price set by U.S. manufacturers for insulin was $98.70. Studies also suggest that spending on insulin has almost tripled in recent years, resulting in decreased insulin affordability and usage.
For this reason, the goal of the Medicare insulin cap was to make insulin more affordable for individuals covered by Medicare. This cap applies across the nation to all people enrolled in Medicare.
This cap does not benefit people not enrolled in Medicare. However, those with commercial health insurance rather than Medicare may have access to different insulin caps, depending on their state of residence.