Insulin Access: Insurance Covers Cost

Insulin is a life-saving medication for millions of people with diabetes, but its high cost has led to many patients rationing or skipping doses, which can lead to serious health complications. While insulin prices have increased over the years, there are various ways for people to access insulin for free or at a reduced cost, whether they have insurance or not. This includes government programs like Medicare and Medicaid, manufacturer savings cards, coupons, patient assistance programs, and community health centres.

Medicare Part B and Part D

Medicare is the federal health insurance program for people aged 65 or older. However, you may be eligible for Medicare earlier if you have a disability, end-stage renal disease (ESRD), or amyotrophic lateral sclerosis (ALS).

Medicare Part B

Medicare Part B (Medical Insurance) covers insulin if you use an insulin pump that's covered under Part B's durable medical equipment benefit. Part B does not cover insulin pens or insulin-related supplies like syringes, gauze, and alcohol swabs. If you use a covered insulin pump, your cost for a month's supply of Part B-covered insulin is capped at $35. If you get a 3-month supply of Part B-covered insulin, your costs can't be more than $35 for each month's supply. This means you'll generally pay no more than $105 for a 3-month supply of covered insulin.

Medicare Part D

Part D covers injectable insulin that isn't used with a traditional insulin pump, insulin used with a disposable insulin pump, certain medical supplies used to inject insulin, and insulin that's inhaled. The cost of a one-month supply of each Part D- and Part B-covered insulin is capped at $35, and you don’t have to pay a deductible for insulin. If you get a 3-month supply of insulin, your costs can't be more than $35 for each month's supply of each covered insulin. This means you'll generally pay no more than $105 for a 3-month supply of covered insulin. Under Part D, the $35 cap applies to everyone who takes insulin, even if you get Extra Help.

Medicaid

To determine eligibility for Medicaid, people can visit HealthCare.gov, which will direct them to their state's specific site and help explain the unique program features in their state. Eligibility varies by state, with some states having less strict eligibility rules for children and pregnant people than for other adults. No matter which state someone lives in, if they are having trouble paying for their or their child's diabetes care, they can check their eligibility for Medicaid or other insurance help at HealthCare.gov.

To see what supplies are covered in a specific state, people can check with their state Medicaid agency at Medicaid.gov. While Medicaid is partly funded by the federal government, decisions about coverage are left to each state. A small number of states do not cover any diabetic supplies, but most cover some or all of the following:

• Disposable needles for syringes
• Blood glucose meters
• Glucose test strips to use in the meter
• Insulin pumps
• Lancets to check blood glucose
• Acetone testing strips
• Ketone testing strips
• Urine glucose-ketone testing strips
• Blood glucose control and calibration solutions
• Glucagon emergency kits

Private health insurance

In the US, there are efforts to make insulin more affordable, and there are some caps on insulin costs for people with private insurance. For example, legislative proposals in Congress propose a $35 per month cap on what people with private health insurance would have to pay out of pocket for insulin. This cap could provide financial relief to at least 1 out of 5 insulin users with different types of private health insurance.

In addition, approximately half of all states and the District of Columbia have enacted legislation that caps co-payments on monthly insulin, and some also limit cost-sharing for supplies.

If you have private insurance and are struggling to afford your medication, most major insulin manufacturers offer co-pay assistance. Co-pay coupon cards can be used by anyone, regardless of income, to reduce your out-of-pocket costs at the pharmacy.

It's important to note that insurance plans and their prices change every year, so it's recommended to double-check that your drugs and health care providers are still covered before renewing your plan.

Patient Assistance Programs

Novo Nordisk's PAP is called NovoCare. To be eligible, patients must be US citizens or legal residents, have a total household income that is at or below 400% of the federal poverty level (FPL), have Medicare or no insurance, and not be enrolled in or qualify for any other federal, state, or government program such as Medicaid, Low-Income Subsidy, or Veterans Affairs (VA) Benefits. There is no registration charge or monthly fee for participating in this program. Applications are available online in English or in Spanish as a paper/PDF form.

Sanofi's PAP is called the Sanofi Patient Connection (SPC) Patient Assistance Program (PAP). Qualified low- and middle-income patients may receive free medication through this program. Additionally, patients who have already applied to the SPC PAP and have an urgent need for medication can call 1-888-847-4877 and request a one-time 30-day supply of medication at no cost via the Sanofi Temporary Access Program.

Lilly's PAP is called the Insulin Value Program. As of March 1, 2023, Lilly has expanded this program to cap out-of-pocket insulin costs for legal US residents to $35 or less per month. Whether you have commercial insurance or no insurance, you can fill your monthly prescription of Lilly insulin for $35 or less. For commercially insured patients who fill at a participating pharmacy, Lilly automatically caps out-of-pocket costs at $35 for their insulins. Some pharmacies may not participate, so if that is the case, you can visit InsulinAffordability.com to immediately download a co-pay Insulin Value Program savings card to receive Lilly insulins for $35 per month, or you can call the Eli Lilly Solutions Center at 833-808-1234. Make sure you indicate that you have insurance as the codes for insured and uninsured patients are different. If you do not have insurance and are a legal US resident, visit InsulinAffordability.com to immediately download a co-pay Insulin Value Program savings card to receive Lilly insulins for $35 per month, or you can call the number above. Take that digital or printed card to your local pharmacy. When requesting the card, make sure you indicate that you are an uninsured/cash payer, as the codes for insured and uninsured patients are different.

Manufacturer savings cards

Eli Lilly Savings Cards

Eli Lilly offers savings cards for the following insulin products: Basaglar (insulin glargine), Humulin R (insulin regular), and Lyumjev (insulin lispro). These savings cards can reduce copays for these medications to as little as $25 for a 30-day supply. However, it's important to note that your doctor may still need to submit a prior authorization if the insulin you need is not a preferred medication under your insurance plan.

Novo Nordisk Savings Card

The Novo Nordisk savings card allows patients with insurance to save on multiple insulins, including Fiasp (insulin aspart), Novolog (insulin aspart), and Tresiba (insulin degludec). This card offers patients the opportunity to pay between $25 and $35 for a 30-day supply of these medications for up to 2 years. Additionally, some offers may include a free box of Novo Nordisk needles.

Sanofi Aventis Savings Cards

Sanofi Aventis savings cards can reduce copays to as little as $0 for their insulin products, depending on the specific insulin product. The savings vary depending on the individual insulin product. Sanofi Aventis offers savings cards for the following medications: Apidra (insulin glulisine), Admelog (insulin lispro), Lantus (insulin glargine), Soliqua 100/33 (insulin glargine/lixisenatide), and Toujeo (insulin glargine).

It's important to note that eligibility requirements and restrictions may apply for these manufacturer savings cards. For example, patients enrolled in certain federal or state healthcare programs, such as Medicaid or Medicare, may not be eligible for some of these savings cards. It's recommended to carefully review the eligibility criteria and terms and conditions for each card.

Frequently asked questions