Does the $35 insulin cap apply to Medicare prescription drug coverage?

The $35 copayment cap for insulin applies only to certain Medicare prescription drug plans that have chosen to participate in the treatment of diabetes. This provision was introduced by the Centers for Medicare and Medicaid Services (CMS) in 2021 to help reduce out-of-pocket costs for Medicare beneficiaries who use insulin.

Under the Part D Senior Savings Model, participating Medicare prescription drug plans are required to cap copayments for a 30-day supply of insulin at $35 for eligible beneficiaries throughout the year. This means that beneficiaries who use insulin will pay no more than $35 out-of-pocket for each 30-day supply of insulin, regardless of whether they are in the initial coverage period, coverage gap, or catastrophic coverage phase of their plan.

It's important to note that not all Medicare prescription drug plans participate in the Part D Senior Savings Model, and the $35 copayment cap only applies to insulin and not to other prescription medications. Additionally, beneficiaries who use insulin may be eligible for additional assistance with their medication costs, such as through the Extra Help program or other state and federal programs.

While the $35 copayment cap for insulin is an important benefit for eligible Medicare beneficiaries, it only applies to certain prescription drug plans and does not apply to all medications or all phases of Medicare prescription drug coverage.

MedHelpCenter.us recommends that you call the Senior Health Insurance Agency at 813-592-8568 for further explanation.