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$35 Insulin is a Hot Topic, But Who Will Benefit?

Chalen Jackson
Accounts Manager
Senior Marketing Specialists


When CMS announced the finalization of the Part D Senior Savings model on May 26, the frantic calls began. $35 dollar insulin makes for a big headline, and clients began calling. Everyone, agents included, wanted to know more about this new program. So, what is the deal with $35 insulin, how does it work, and who can get it?

It all starts with the Part D Senior Savings Model, designed specifically to test the efficacy and feasibility of changing the rules surrounding compensation for certain drugs, namely, insulin. This works by removing disincentives surrounding a Plan Sponsor’s ability to offer lower cost sharing during the coverage gap, or “Donut Hole”. That is the core of why this is such a big deal: this program allows Plan Sponsor’s to offer a flat, predictable (in this case, no more than $35) copay for insulins, no matter what “coverage phase” a beneficiary is in. Haven’t met your deductible? $35. Donut Hole? $35, and the same everywhere in between.

So how does it work? Why are plans now able to do this, and what was stopping them before? A key facet of plan design for Part D coverage included the times at which manufacturers of drugs could contribute to cost sharing, which currently is prohibited during the coverage gap. The new Part D Senior Savings Model allows for plans to continue to receive cost-sharing from manufacturers, without bearing additional financial burden. So, what is really important to know about all this?

  1. This is a test. This Pilot Program has been set up for the 2021 plan year to involve both Plan Sponsors and Manufacturers to determine how effective this new method can be in achieving better health outcomes and maintaining competitiveness in the market.
  2. The program is voluntary. Not all plans are involved, and not all insulins are involved. The CMS announcement from May 26, 2020 indicated that, “over 1,750 standalone Medicare Part D prescription drug plans and Medicare Advantage plans with prescription drug coverage have applied to offer lower insulin costs through the Part D Senior Savings Model for the 2021 plan year”. Until plan details are finalized closer to Annual Enrollment, we will not know which plans, or even how many standalone PDP’s compared to MAPD’s are involved.
  3. Not Everyone will benefit. Due to the nature of this being a pilot program, it will NOT be available to everyone in every area. In addition, even if a plan in your area includes this benefit, we must be careful to take ALL the client’s drugs in to account, not only insulin. These plans will not fit every diabetic client.

So, what can we do to prepare? Keep an eye our for more announcements from CMS. They will be releasing more news as AEP draws nearer. Sign up for our Carrier Rollouts in July to get Sneak Peaks on new plans and who may be participating. Anticipate questions from clients who may or may not have access to plans with $35 insulin, and prepare alternatives, like our CleverRx discount program. Most importantly, reach out to Senior Marketing Specialists with any Questions!

Sources:

www.cms.gov/newsroom/press-releases/president-trump-announces-lower-out-pocket-insulin-costs-medicares-seniors
innovation.cms.gov/innovation-models/part-d-savings-model
innovation.cms.gov/media/document/hpi-vbid-partd-models-overview-slides