Copay Caps for Insulin Lower Total Spending for Medicare Beneficiaries


The Medicare Part D Senior Savings Model — a CMS effort to test $35 copays for insulin — led to lowered total costs for beneficiaries.

Medicare beneficiaries save by capping insulin copays at $35, according to a research letter published recently in JAMA.1 The study looked at the Medicare Part D Senior Savings Model in both traditional Medicare standalone Part D and Medicare Advantage Prescription Drug.

The Part D Senior Savings Model is a voluntary program that allowed Medicare prescription drug plans to offer 30-day supplies of insulin at or below a $35 copayment. It began in January 2021 as a test of the $35 cap on insulin copays and will continue through 2033. This copay cap for insulin will be required for all Part D plans beginning in 2023 as part of the Inflation Reduction Act.

Investigators Khrysta Baig, MSPH and Stacie B. Dusetzina, Ph.D., compared premiums and total spending for long-acting insulin users selecting prescription drug plans in 2022 and estimated potential savings for beneficiaries selecting Senior Savings Model-participating plans. Dusetzina is a professor of health policy and Ingram Professor of Cancer Research at Vanderbilt University Medical Center in Nashville. Baig is a Ph.D. student in the health policy program at Vanderbilt University School of Medicine.

In this cross-sectional analysis, Baig and Dusetzina included prescription drug plans that covered at least one of four commonly filled long-acting insulin pens: Sanofi’s Lantus SoloStar, Novo Nordisk’s Levemir FlexTouch, Lilly’s Basaglar KwikPen, and Novo Nordisk’s Tresiba FlexTouch (Novo Nordisk). They standardized 30-day supplies to five 3-mL/100-unit pens. They also calculated annual expected spending on insulin for 12 insulin fills, assuming six fills in the initial coverage phase and six fills in the coverage gap.

In 2022, among plans that covered the long-acting insulin pens, model-participating traditional Medicare standalone Part D plans had the highest mean annual Part D premiums. Within these plans, mean annual total spending (including premiums, deductibles, and co-payments/co-insurance) was $1,162 compared with $1,962 for those with enhance plans not participating in the model and $1,926 for basic plans that were not eligible for participation.

Medicare Advantage Prescription Drug plans that participated in the model had the lowest mean annual Part D premiums. Among these plans, mean annual total spending for those who were in model-participating plans was $522 compared with. $1,137 for nonparticipating enhanced and $1,968 for basic plans.

The authors said limitations of the study included a lack of data on beneficiary plan switching, the number of insulin users by plan type, and other medication use. Additionally, this analysis considers only 2022 plan choices.

This article originally appeared on Formulary Watch.


1. Baig K, Dusetzina SB. Premiums and out-of-pocket spending for long-acting insulins under the medicare part D senior savings model. JAMA. 2022 Nov 11;e2217232. doi: 10.1001/jama.2022.17232.

Related Videos
Related Content
© 2024 MJH Life Sciences

All rights reserved.