![]() You will pay the same amount for your drugs from the initial payment stage through the donut hole. The donut hole is considered closed because as of January 2020 you no longer have to pay more for your drugs while you’re in that coverage stage. The donut hole – also called the “coverage gap” – is still one of the four Medicare Part D payment stages. Types of insulin will be covered on their plan and at which cost-sharing.The Medicare Part D donut hole technically “closed” on January 1, 2020, but it’s not exactly going away completely. You can use our Formulary Browser, Q1Rx Drug finder or contact the Medicare drug plan for details about which specific With the National Drug Codes identifying the insulin products. Of "select" insulin covered by the Senior Savings Model (SSM) along Please see the table below showing some of the different types and forms However, since the IRA extends over the SSM, Catastrophic Coverage of SSM "select insulin" will still not exceed $35. The Senior Savings Model does not apply to your Catastrophic Coverage phase (where you will pay 5% of the retail drug cost). Initial deductible, initial coverage phase, and the Coverage Gap (or Donut Hole). Throughout most phases of your drug coverage including your plan's: Of different types of insulin at a maximum co-pay of $35 per month Medicare Advantage plans with drug coverage (MAPDs) will offer coverage (SSM or Model), about 30% of all stand-alone Medicare Part D plans (PDPs) and Will need to look within your plan's documentation (Evidence ofĬoverage) or printed formulary or online to learn more about howĭifferent insulin products are covered by your Medicare drug plan.Īs part of the CMS 2023 " Part D Senior Savings Model" (3) Identifying lower-costing SSM "select insulin" on a formulary Matter what the tier, you pay no more than $35 for the 30-day supply. Tier-level only helps your plan organize the drugs) – in the end, no Level for your insulin is almost irrelevant to what you pay (and the Insulin products on Tier 6 (since all insulins must have a cost-sharing Inflation Reduction Act - your drug plan will organize all other Model "select insulins" on a Tier 3 (because the Senior Savings ModelĪpplied to only certain insulin products) - and then, to accommodate the (2) Question: So will my plan have different formulary tiers for SSM insulin and IRA insulin?įor example, your Medicare drug plan may organize the Senior Savings For example, you may find that your plan offers “select insulins” for $11 or $33 (depending on whether preferred or standard network pharmacy) – and all other formulary insulin products for the mandatory $35 (or less) co-pay. It is possible that your 2023 Medicare Part D plan may offer two different programs that both provide insulin for $35 or less. ![]() (1) Question: Can my 2023 Medicare Part D plan have different cost sharing for different insulin without exceeding $35 a month? Must offer all formulary insulin products at a maximum $35 copay. Offer certain insulin products at a $35 or lower co-pay - and at the same time, Possible that a 2023 Medicare Part D or Medicare Advantage plan may $35 or less copays for some "select insulin products) - it is Included the now somewhat-redundant Senior Savings Model (allowing for Since the Inflation Reduction Act was passed in mid-2022 - and about 30% of Medicare drug plans had already submitted 2023 drug plan designs that So yes, in 2023, there are two similar programs that are both focused on providing low-cost insulin products to members of Medicare Part D drug plans or Medicare Advantage plans with drug coverage (MAPDs) and here is how you may find the two programs working together. Phase where you will pay only 5% of the retail price not to exceed $35).īlending the 2023 Senior Savings Model into the 2023 Inflation Reduction Act. (IRA) introduces an insulin cost-saving provision - similar to the existing Senior Savings Model (SSM) - with coverage for all formulary insulin at a $35 (or less) monthly copay throughout all phases of Medicare Part D plan coverage (up to the 2023 Catastrophic Coverage Find a 2023 Medicare Advantage Plan by Drug CostsĪll Insulin products covered by your Medicare Part D drug plan will cost $35 or less for a 30-day supply.2023 Medicare Advantage Plan Benefit Details.2023 Medicare Advantage Plans State Overview.IRMAA: Higher premiums for higher incomes.Understanding Your Explanation of Benefits.Medicare plan quality and CMS Star Ratings.Find Medicare plans covering your prescriptions.Q1Rx Drug-Finder: Compare Drug Cost Across all 2023 Medicare Plans.Browse Any 2023 Medicare Plan Formulary (or Drug List).Find a 2023 Medicare Advantage Plan (Health and Health w/Rx Plans).
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