SAVING MONEY IN MEDICARE WITH INSULIN
THE MEDICARE PART D SENIOR SAVINGS INSULIN MODEL
On March 11, 2020, the Centers for Medicare and Medicaid Services (CMS) announced the Part D Senior Savings Model (the Model)to reduce beneficiary cost sharing for insulin products in Medicare Part D.1The Model will take effect on January 1, 2021,and is designed to make prescription drugs more affordable for insulin-taking Medicare beneficiaries and restructure how plan sponsors offer supplemental benefits in the coverage gap. Under this voluntary model, plans select a set of insulins to cover from a list of Model-participating manufacturers. Plans cover the selected insulins at a maximum $35 copay per 30-day supply in the first three phases of the Part D benefit (i.e., deductible, initial coverage phase, and coverage gap), resulting in consistent and predictable out-of-pocket insulin costs for beneficiaries.
What are the guidelines for participating in the Model?
What types of plans are Model-eligible?
Model participation is available in all states and territories to plan sponsors for enhanced alternative Part D plans. This applies to both standalone prescription drug plans (PDPs) and Medicare Advantage plans with prescription drug coverage (MA-PDs), but not to employer group waiver plans (EGWPs). Chronic and institutional special needs plans (C-SNPs and I-SNPs) are eligible, but dual eligible special needs plans (D-SNPs) are not. Plan sponsors can select which of their plan offerings to include in the Model.
Which beneficiaries are eligible to enroll?
Non-low income (NLI) beneficiaries who enroll in a Model-participating plan will pay the flat copays for selected insulins. Which insulins do plans need to cover? As a requirement of participation, Part D plans must cover a set of insulin products marketed by pharmaceutical manufacturers participating in the Model. On March 23, 2020 CMS published a list of participating manufacturers and national drug codes (NDCs) on the Model website3,4. The Model requires plans cover a set of insulins that includes, at minimum, one vial and pen dosage form of the following four insulin types: rapid-acting, short-acting, intermediate-acting, and long-acting. CMS acknowledges some plan sponsors may cover a product or line of products for a particular type of insulin that exists in only one dosage form (i.e., vial or pen). In these cases, plan sponsors would not need to cover both dosage forms for that type of insulin to meet Model requirements. CMS offers the option, and strongly encourages plan sponsors to also include other insulin formulations, such as mixes and concentrated forms. CMS specifies the list of NDCs may be updated periodically “...based on NDC or drug changes from participating manufacturers”4.How do participating plans structure the benefit? Participating Part D plans are required to offer a supplemental benefit with a maximum copay of $35 per 30-day supply in the deductible, initial coverage, and coverage gap phases of the benefit. Each Model insulin can have its own unique copay. If plans choose to offer a lower copay, it must remain constant throughout the three benefit phases. The copay maximum applies to preferred and non-preferred retail and mail pharmacies. Model insulins not covered on the formulary would not be subject to these maximum copays.
Reducing insulin costs for seniors
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