Yes, Medicare covers insulin for diabetes treatment, but beneficiaries may need to enroll in a Medicare Part D prescription drug plan for more comprehensive insulin coverage. Medicare Part B covers the insulin used with traditional insulin pumps, while Part D covers more usages.
Keep reading for more details about Medicare insulin coverage, including the types of insulin covered by Medicare and how much it costs.
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Diabetes a Common Concern For Medicare Beneficiaries
Approximately 11.6% of Americans (38.4 million people) currently have diabetes, and 1 in 5 may not know they have diabetes. Diabetes is a growing health concern among the entire population, with 1.2 million Americans diagnosed with diabetes each year.
Treating diabetes can be expensive. More than 8.3 million people use insulin to control their blood sugar, making diabetes the most costly chronic condition in the United States. Learn how Medicare beneficiaries may receive some support in paying for insulin.
How Medicare Covers Insulin
Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). Part A does not cover insulin, though it covers hospital stays related to diabetes. Part B covers insulin used with a standard non-disposable insulin pump.
Part B also covers the equipment needed for taking insulin, such as blood sugar self-testing supplies. People who take insulin to treat diabetes can typically receive up to 300 lancets and 300 blood sugar testing strips every three months. Blood sugar monitors are also covered.
For more comprehensive coverage for insulin, Medicare beneficiaries should consider enrolling in a stand-alone Part D plan for prescription drug coverage or a Medicare Advantage Plan that bundles in Part D.
Eligibility Criteria
Medicare beneficiaries may be eligible for Part B-covered insulin if they meet the following criteria:
- Use an insulin pump worn outside the body
- Use an insulin pump that is not disposable
- Are medically required to use an insulin pump
Part B does not cover insulin delivered through syringes, insulin pens, inhaled insulin, or disposable insulin pumps. Instead, Medicare Part D covers that form of insulin.
Medicare Part D and Insulin Coverage
Medicare Part D helps cover the cost of prescription drugs, including insulin. It does not automatically come with Original Medicare. Beneficiaries seeking drug coverage can buy a stand-alone Part D drug plan from a Medicare-approved private company.
Unlike Original Medicare, which only covers insulin used with traditional insulin pumps, Part D plans can cover a wide range of insulin products. For example, Part D plans may cover insulin that is inhaled, injected with a syringe or prefilled pen, or used with a disposable patch pump. However, not all plans may cover the specific insulin product you use, so it is important to check the plan’s list of covered medications before enrolling.
Medicare Part D also covers some medical supplies beneficiaries need to inject insulin, such as alcohol swabs, syringes, insulin pens, and gauze. Supplies not directly required to inject insulin, such as sharps disposal containers, are not covered.
Medicare Advantage Can Enhance Insulin Coverage
Medicare Advantage is a popular alternative to Original Medicare sold by private insurance companies. These plans are required to cover the same Part A and Part B benefits as Original Medicare. This means all Medicare Advantage Plans cover the same insulin pumps and supplies as Medicare Part B.
However, many Medicare Advantage Plans cover additional benefits. For example, plans often bundle Part D drug coverage, extending insulin coverage to include things like inhaled and injected insulin and insulin patches used with a disposable pump. However, coverage may be limited to specific brands of insulin pumps or require prior authorization before covering supplies used with the pump.
In addition to Part D, Medicare Advantage plans may cover a wide range of additional benefits to help beneficiaries stay healthy. These include eye exams, hearing exams, dental care, fitness programs, and coverage for over-the-counter drugs. If you need specific benefits or insulin types, work with a licensed agent or broker to find a Medicare Advantage Plan that offers coverage.
Special Needs Plans
A Special Needs plan (SNP) is a type of Medicare Advantage Plan designed for people with specific health needs. These plans have three types:
- C-SNP: The Chronic Condition Special Needs Plan is a type of SNP that enrolls people with certain health conditions, like diabetes.
- D-SNP: The Dual-Eligible Special Needs Plan is for people with both Medicare and Medicaid
- I-SNP: The Institutional Special Needs Plan is for people who live in long-term care facilities
All SNPs are required to cover Part A, Part B, and Part D. They tailor their benefits, provider networks, and drug formularies based on the needs of the group of beneficiaries they enroll. For example, in a C-SNP for people with diabetes, the plan may cover additional benefits like routine foot care visits or allowances for healthy food.
Types and Costs of Insulin Covered by Medicare
Medicare insulin coverage depends on how you take your insulin. The chart below compares the types of insulin covered by each part of Medicare, as well as how much it costs.
Types of Insulin Covered | Insulin Cost | |
|---|---|---|
Part B | Insulin that’s administered with an external durable insulin pump | $35 maximum per month’s supply |
Prescription Drug Plan (Part D) | Insulin that’s injected, inhaled, or used in a disposable insulin pump | $35 maximum per month’s supply; actual costs may be lower based on plan |
Medicare Advantage | Same as Part B and Part D if MA Plan includes drug coverage | $35 maximum per month’s supply; actual costs may be lower based on plan |
Ways to Make Insulin More Affordable
The cost of Part B-covered or Part D-covered insulin is now capped at $35 per month, but some beneficiaries still face challenges paying for their insulin. If you’re wondering how to afford insulin on Medicare, look into the following resources:
- Part D Extra Help: Extra Help is a Medicare program that helps low-income beneficiaries pay for their Part D premiums, deductibles, coinsurance, and copayments.
- Medicaid: State Medicaid programs provide health coverage to eligible low-income people. While Medicaid coverage varies from state to state, insulin is typically available for free or at a low cost.
- State programs: Several states offer programs that help Medicare beneficiaries pay for prescription drugs, such as insulin. For example, New York has the Elderly Pharmaceutical Insurance Coverage program, while Wisconsin offers the SeniorCare program.
- Manufacturer programs: Pharmaceutical companies may provide free or low-cost insulin to people who meet certain eligibility requirements. Contact the manufacturer of your insulin for details.
- Pharmacy savings programs: Some chain pharmacies offer programs to help patients find lower costs for their prescriptions. Ask your pharmacist for details.
How to Choose the Best Medicare Options For Your Insulin Needs
If you have diabetes, consider your insulin needs when comparing Medicare Advantage or prescription drug plans. Here are some key tips to remember before choosing a plan.
- Review the plan’s formulary: Each stand-alone prescription drug plan or Medicare Advantage Plan with Part D has a list of covered drugs. Review the list to find out if your insulin products and other diabetes medications are covered. If not, you may prefer other plans.
- Compare out-of-pocket costs: The cost of covered insulin products is capped at $35 per month, but actual out-of-pocket costs may be lower in some plans. Compare plans to see if there are lower-cost options.
- Confirm network pharmacies: The $35 insulin cap applies at both in-network and out-of-network pharmacies, but for other diabetes drugs, you may pay more if you fill prescriptions outside the network. Confirm your preferred pharmacy is in the plan’s network.
- Review coverage rules: Medicare drug plans and Medicare Advantage Plans may set rules, such as requiring members to try a lower-cost insulin before a more expensive type is covered.
- Consult a professional: For help understanding Medicare insulin coverage and choosing an option that suits your insulin needs, consider talking to a trusted insurance agent.
Putting It All Together
Medicare covers insulin that beneficiaries need to manage their diabetes. Medicare insulin coverage is primarily offered through Part D, though Part B covers the insulin beneficiaries use with traditional insulin pumps.
To help people with diabetes stay healthy, Medicare covers many other diabetes-related services. In addition to insulin, it covers things like insulin pumps, diabetic test strips, and diabetic self-management training. Some Medicare Advantage Plans cover additional benefits for diabetic care. To find a plan that covers your diabetic care needs, work with a trusted agent.