Medicare Plan Finder probably won’t note the new $35 cap on out-of-pocket insulin

A big cut in prescription drug prices for some Medicare beneficiaries starts next year, but those savings aren’t easy to find.

Congress in August approved a $35 cap on what seniors would pay for insulin as part of inflation-reducing legislation including free vaccines and other Medicare improvements. But the change came too late to add to the Medicare Plan Finder, the online tool that helps beneficiaries sort through dozens of drug and medical plans for the best deals.

Officials say the issue only affects the 2023 plan.

To correct the expected enrollment error, Medicare officials will give beneficiaries who use insulin the opportunity to change plans next year. They can make a change through a special enrollment period after December 8 and in “exceptional circumstances” throughout 2023. Usually, people are locked up for the whole year.

The Centers for Medicare and Medicaid Services provides a basic description of coverage in a document distributed to the State Health Insurance Assistance Program, or SHIP, which assists Medicare enrollees in each state. Although Medicare has not circulated the document, beneficiaries can obtain more information by contacting their local SHIP office. CMS officials would not answer questions about whether the ability to change plans would be automatically granted.

“We are pleased that CMS is offering a special enrollment period that will allow insulin users to change plans in 2023,” said Chris Rigg, director of the Ohio Senior Health Insurance Information Program.

In some cases, a special enrollment period can be avoided, said Janet Stellmon, director of the Montana State Health Insurance Assistance Program. If the plan charges a copayment of more than $35 for a member’s insulin, a ship counselor can ask the plan to correct the error. “Plans usually try to speed it up,” said Stellmon, who helped one beneficiary save $565 a month on insulin.

Medicare patients spent $1 billion on insulin products in 2020 — four times the amount in 2007, with some paying as much as $116 a month, KFF found. Americans paid an average of five to 10 times more for insulin in 2018 than other countries, a recent study found. About 3.3 million people with Medicare rely on one or more insulin products to control blood sugar levels.

The $35 copay for injectable insulin products is effective Jan. 1 and July 1 for those who use an insulin pump.

When beneficiaries who use insulin now check Plan Finder, prices can be seen as thousands of dollars a year instead of the $420 maximum set by law. An incorrect price can also distort the cost of other drugs, depending on which coverage level patients reach. For example, once both the plan and the patient spend a total of $4,660 on all drugs the following year, the member will pay no more than 25% of the cost for non-insulin drugs.

It is extremely difficult for consumers to evaluate policy options without a plan finder. One plan may have a minimum price for one drug but not another Or a plan may have the lowest premiums but higher drug costs. Or a preferred pharmacy in one plan may be excluded from another plan

Medicare officials warn consumers about the problem. “This new $35 cap may not be reflected when you compare plans,” according to a warning that pops up during a plan finder search. “You should talk to someone for help comparing plans,” it says, directing readers to the Medicare Help Line — 800-633-4227 — or a counselor with SHIP. It does not mention the option to change plans after the Dec. 7 enrollment deadline.

But both ship counselors and representatives answering the Medicare help line rely on the same flawed plan finder.

Georgia Gerdes at AgeOptions in Oak Park, Illinois, trains people across the state to help Medicare beneficiaries. He said he searches for policies without adding insulin to a client’s medication list and separately searches for plans that cover the type of insulin the client takes. He then reviews those lists to see which non-insulin medications are on the insulin list and manually adds up the $35 monthly insulin cost before making a recommendation.

Medicare beneficiaries filled prescriptions for at least 114 types of insulin in 2020, and those who did not receive low-income subsidies were out-of-pocket on average $572, according to KFF research.

But drug plans don’t have to cover all injectable insulin, says Tatiana Fassiux, an education and training specialist at California Health Advocates. “It’s all about formula,” he added, referring to the plan’s covered drugs.

Related topics

Contact us Submit a story tip

Leave a Reply

Your email address will not be published.