Medicare Part D to Cap Insulin Cost at $35 per Month in 2023

Published on October, 4 2022 by Michelle Berney

Individuals with Medicare Part D drug coverage who take insulin that is on their plan’s formulary will have their co-pays capped at $35 per insulin per month. The $35/month cost is not subject to the plan’s annual deductible (if the plan has one), meaning that one can benefit from the $35 copay before meeting any deductible. Individuals will also pay the $35 copay should they reach Catastrophic Coverage.

Here are some important points to remember:

  • In order to benefit from the $35/month copay maximum, the insulin must be on the plan’s formulary (list of covered drugs).
  • Due to timing, the Medicare.gov planfinder will not reflect the change to insulin pricing for the upcoming Annual Election Period (October 15 – December 7).
  1. When assisting clients with Extra Help/LIS, with a Planfinder search, you can enter all of their drugs as usual. These clients will continue to benefit from lower cost sharing for all prescriptions.
  2. When assisting clients without Extra Help/LIS, it is recommended to:
    • First do a search without the insulin to see which plan(s) cover all other medications at the lowest cost, with the fewest restrictions possible, which work with their preferred pharmacy.
    • Add in the insulin to the Planfinder search to see which plans have the insulin on their formularies. To estimate total drug costs for the year, add in $420 ($35 x 12) per insulin used to the cost of the initial search. For example, if someone uses one type of insulin, add in $420 to the total plan cost for the calendar year. If someone uses two types of insulin, add in $840 to the total plan cost for the calendar year. (Note: the cost of insulin may be less than $35 in some plans; check with plan to confirm exact cost.

Individuals with Full or Partial Extra Help/LIS will continue pay the applicable copays, as will EPIC members.