Paul Sanchez
Insulin is a crucial medication for millions of people with diabetes, but it can be costly. In the US, insulin access and affordability are determined by factors such as insurance coverage, income, and state legislation. Understanding how medical insurance covers insulin is essential for patients to manage their diabetes effectively. This involves navigating the complexities of insurance plans, Medicare and Medicaid provisions, cost-sharing initiatives, and the availability of alternative financial assistance.
| Characteristics | Values |
|---|---|
| Does Medicare cover insulin? | Medicare Part B covers insulin if you use an insulin pump that's covered under Part B's durable medical equipment benefit. |
| Does Medicare Part D cover insulin? | Medicare Part D includes insulin and certain medical supplies used to inject insulin. |
| How much does insulin cost with Medicare Part D? | The cost of a one-month supply of insulin is capped at $35, and you don’t have to pay a deductible for insulin. |
| How can you save money on insulin? | You can save money on insulin through coupons, patient assistance programs, and copay savings programs. |
| How to know if your insurance covers insulin? | Check the drug formulary, a list of covered medicines and their associated tiers. |
| Does insurance cover insulin pumps? | Insurance companies will usually require you to meet certain criteria before they will cover the cost of an insulin pump. |
| Does insurance cover CGMs? | Similar to insulin pumps, if you are not currently using a CGM but want it to be covered, you may need to meet certain criteria. |
| Does Medicaid cover insulin? | Most Medicaid enrollees receive insulin for free or at a significantly reduced cost. |
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What You'll Learn
Insulin pump coverage
In the United States, insulin coverage depends on the type of insurance plan you have. Medicare Part B (Medical Insurance) covers insulin if you use an insulin pump that's covered under Part B's durable medical equipment benefit. However, Part B does not cover insulin pens or insulin-related supplies. On the other hand, Medicare Part D includes insulin and certain medical supplies used to inject it. As a result of the Inflation Reduction Act of 2022, Medicare Part D enrollees' monthly cost-sharing for insulin is capped at $35.
Medicaid is a state and federally funded health insurance program that provides coverage to certain lower-income individuals and families, including children, parents, people who are pregnant, elderly, or disabled. Each state decides which diabetes medications and supplies are covered by its Medicaid program. Most Medicaid enrollees receive insulin for free or at a significantly reduced cost.
In the Province of British Columbia, PharmaCare covers certain insulin pump supplies if you are covered under Plan C (B.C. Income Assistance). Insulin aspart originator (NovoRapid) is covered for people using Omnipod, Medtronic, Ypsomed, and Tandem insulin pumps. If you meet the criteria for coverage of a pump, your specialist will submit a Special Authority request to PharmaCare. It is important to wait for the approval letter before purchasing your insulin pump, as PharmaCare cannot provide retroactive coverage for purchases made before approval is confirmed.
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Medicare Part B and D coverage
Medicare Part B (Medical Insurance) covers insulin if you use an insulin pump that is covered under Part B's durable medical equipment benefit. It does not cover insulin pens or insulin-related supplies like syringes, needles, alcohol swabs, and gauze. If you use an insulin pump, you will pay $35 or less for a month's supply of insulin. If you get a 3-month supply of insulin, you will pay no more than $105. If you have Medicare Supplement Insurance (Medigap) that pays your Part B coinsurance, your plan should cover the cost of insulin.
Medicare Part D includes insulin and certain medical supplies used to inject insulin. The cost of a one-month supply of each Part D-covered insulin product is capped at $35, and you don’t have to pay a deductible for insulin. This applies to everyone who takes insulin. If you get a 3- or 4-month supply of insulin, your costs can’t be more than $35 for a month’s supply of each covered insulin.
The Inflation Reduction Act has helped make insulin more affordable for Medicare beneficiaries. You can save money on insulin by comparing pharmacies for the best prices, asking your doctor about generic or less expensive options, using manufacturer rebates and coupons, and enrolling in a stand-alone Medicare Part D plan or getting drug coverage as part of a Medicare Advantage plan.
Some manufacturers offer co-pay assistance programs to help reduce your out-of-pocket costs. Insulin manufacturers provide insulin at no cost through their patient assistance programs to people who are uninsured and meet income eligibility requirements. Follow-on brands of insulin are also available at 50% off the current list price.
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Insulin co-payment
Insulin is a critical medication for people with diabetes, but the cost can be a significant financial burden for many. While medical insurance may cover insulin, the specific coverage and co-payment amounts can vary depending on the insurance plan and the state. Here is some information about insulin co-payments:
Medicare Part B:
Medicare Part B covers insulin if you use an insulin pump that is included under the durable medical equipment benefit. However, it does not cover insulin pens or insulin-related supplies like syringes, needles, and alcohol swabs. The cost of a one-month supply of covered insulin is capped at $35, and there is no deductible for insulin. This cap applies to everyone who takes insulin, and it also applies if you have Medicare supplement insurance (Medigap).
Medicare Part D:
Medicare Part D includes insulin and certain medical supplies used to inject it. As a result of the Inflation Reduction Act of 2022, the monthly cost-sharing for insulin under Medicare Part D is capped at $35. This cap applies to all covered insulin products and includes cost-sharing limits.
Medicaid:
Medicaid is a joint state and federally funded program that provides health coverage to certain low-income individuals and families, including children, pregnant women, and people with disabilities. Most Medicaid enrollees receive insulin for free or at a significantly reduced cost. However, each state determines which diabetes medications and supplies are covered through its Medicaid program. Approximately half of the states and the District of Columbia have enacted legislation capping co-payments on monthly insulin, and some also limit cost-sharing for supplies.
Commercial Insurance:
For commercial insurance, it is essential to check with your insurance company to understand which insulins are covered and the expected co-payments. Some manufacturers offer co-pay assistance programs to help reduce out-of-pocket costs. Additionally, patient assistance programs may provide insulin at no cost to those who are uninsured and meet income eligibility requirements.
State-Specific Caps:
Some states have enacted legislation to cap insulin co-payments for state-regulated commercial health insurance plans. For example, Connecticut has a $25 cap for a 30-day supply of insulin, while Delaware has a $100 collective cap for the same period. These caps vary from state to state, and it is essential to check the specific regulations in your state.
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Insulin affordability
Medicare Part B covers insulin if you use an insulin pump under its durable medical equipment benefit. Additionally, Medicare Part D includes insulin and certain medical supplies used for injection. The cost-sharing limit for insulin under Medicare Part D is capped at $35 per month, ensuring that beneficiaries do not pay more than this amount. This cap applies to everyone who takes insulin, regardless of their specific plan.
Medicaid, a joint state and federally funded program, provides health coverage for lower-income individuals and families, including children, pregnant women, the elderly, and people with disabilities. Most Medicaid enrollees receive insulin for free or at significantly reduced costs. However, it is important to note that each state has its own determination of which diabetes medications and supplies are covered under its Medicaid program. Therefore, it is advisable to check with your state Medicaid agency for specific information.
To enhance insulin affordability, companies like Novo Nordisk and Eli Lilly have introduced various initiatives. Novo Nordisk offers immediate supply assistance, providing a free one-time supply of insulin for those at risk of rationing. They also have discounted follow-on brand insulins available at local pharmacies. Eli Lilly, through its Insulin Value Program, offers all its insulins for $35 a month, regardless of insurance status. This program is available at most retail pharmacies, but it does not apply to those enrolled in federal government insurance programs.
Additionally, patient assistance programs (PAPs) provide free or low-cost insulin to eligible individuals. The Sanofi Patient Connection, for example, offers free medication to qualified low- and middle-income patients. Similarly, Novo Nordisk's Patient Assistance Program provides free insulin for 90 days to eligible participants.
While strides have been made to improve insulin affordability, ongoing concerns about potential shortages and the impact on patients remain. It is crucial for those prescribed insulin to have access to affordable and uninterrupted medication.
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CGM coverage
Continuous glucose monitoring (CGM) is a device that can be prescribed to patients treated with insulin and/or have a history of problematic hypoglycaemia. Medicare may cover a CGM and related supplies (such as sensors and transmitters) if a doctor confirms that the patient meets the requirements for Medicare coverage. To qualify for a continuous glucose monitor, patients must:
- Have diabetes mellitus.
- Take insulin or have a history of problems with low blood sugar.
- Have a prescription for testing supplies and instructions on how often to test blood glucose.
- Have been trained (or have had their caregiver trained) to use a CGM as prescribed by their doctor.
Medicare requires patients to use a CGM system with a stand-alone receiver or insulin infusion pump classified as durable medical equipment (DME) to display glucose data. However, patients can use a compatible smartphone, watch, or similar personal device in conjunction with a dedicated CGM receiver, but the receiver must be used at least some of the time for Medicare coverage to apply. As of November 2023, four companies offer CGM systems cleared for use by the FDA: Abbott, Dexcom, Ascensia, and Medtronic.
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Frequently asked questions
Medicare Part B covers insulin if you use an insulin pump that is covered under Part B's durable medical equipment benefit. Medicare Part D, which includes Medicare Advantage Prescription Drug plans (MAPD) and standalone prescription drug plans (PDP), may cover inhaled insulin and injectable insulin not used with an insulin infusion pump.
The cost of a one-month supply of each Part D- and Part B-covered insulin product is capped at $35, and you don’t have to pay a deductible for insulin.
If you are not currently using an insulin pump, insurance companies will usually require you to meet certain criteria before they will cover the cost of an insulin pump. This may involve your doctor completing a prior authorization (PA) or pre-certification form, which will include evidence of medical necessity for an insulin pump.
You can review your health insurance plan to find out if your preferred insulin medication is covered. You can also contact your insurance company directly to ask which insulin products are preferred.
You can save money on insulin through coupons, patient assistance programs, and copay savings programs. Some manufacturers offer co-pay assistance programs to help reduce your out-of-pocket cost. Insulin manufacturers provide insulin at no cost through their patient assistance programs to people who are uninsured and meet income eligibility requirements.
