Medicare provides some coverage for diabetes treatments, including insulin, which is good news for beneficiaries with diabetes. Approximately 1 in 10 Americans (37.3 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 1.4 million Americans diagnosed with diabetes each year.
Treating diabetes can be expensive. In fact, 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.
Does Medicare Cover Insulin?
Both Medicare Part B and Part D provide some coverage for insulin treatments. The following provides a closer look each part of Medicare’s coverage for beneficiaries with diabetes.
Medicare Part D
Medicare Part D, which offers prescription drug coverage, covers injectable and inhaled insulin not used with an insulin pump. It also covers some necessary medical supplies, such as needles, alcohol swabs, syringes, and gauze.
Beneficiaries can purchase Part D through private, Medicare-approved insurance carriers as a stand-alone plan or as part of a Medicare Advantage plan. Premiums vary, though individuals with higher incomes are charged an extra amount on top of the plan premium. The income threshold for this additional charge was at least $97,000 for those filing individually and at least $194,000 for those who are married and filing jointly in 2023.
Another option is to join a Medicare drug plan that participates in the Insulin Senior Savings Model. These plans offer multiple types of insulin coverage for a maximum copayment of $35 per month.
Medicare Part A
Medicare Part A does not cover insulin. Instead, it provides inpatient coverage, which helps pay for medical care provided in hospital, skilled nursing, or hospice facilities.
However, you must have Part A or Part B coverage to get Part D coverage. If you are not eligible for premium-free Medicare Part A, you can purchase it for $274 or $499 each month in 2022, but the prices will increase to $278 or $506 in 2023. The exact amount depends on how long you or your spouse paid Medicare taxes.
Medicare Part B
Medicare Part B covers a variety of diabetes treatments and supplies, including:
- External insulin pumps and supplies
- Blood sugar or glucose testing monitors
- Blood sugar test strips
- Lancet devices for blood sampling
- Control solutions for testing medical equipment
- Therapeutic shoes
It does not cover insulin pens, syringes, needles, alcohol swabs, or gauze. Instead, all of these are covered under Part D.
To enroll in a Part D plan for additional insulin coverage, you must also be enrolled in Part A, Part B, or both. Part B coverage focuses on outpatient care, doctor services, medically necessary durable medical equipment, and preventative services.
In 2022, the cost of Medicare Part B is $170.10 per month, though this will decrease to $164.90 in 2023.
Medicare Part C (Medicare Advantage)
Medicare Part C, also known as Medicare Advantage, often includes Part D drug coverage. This inclusion means all of Part D’s insulin coverages would also apply to Part C plans with Medicare drug coverage. Private insurance companies offer these plans and include Parts A and B coverage at a minimum. However, many provide additional benefits, like the aforementioned Part D coverage, as well as dental, hearing, and vision benefits.
Individuals with diabetes may also get additional coverage by enrolling in a Medicare Special Needs Plan (SNP). SNPs are a type of Medicare Advantage plan that’s only available to people with certain characteristics or diseases. These plans offer specific drug formularies, provider choices, and benefits tailored to meet the needs of the individuals covered. Unlike other Medicare Advantage plans, SNPs work in conjunction with Original Medicare.
Those with diabetes mellitus may be eligible for a Chronic Condition SNP (C-SNP). Other eligibility criteria include being enrolled in Medicare Parts A and B and residing in the plan’s service area.
Medigap (Medicare Supplement)
Medicare Supplement plans, also known as Medigap, do not explicitly cover any insulin costs. However, as these plans work with Original Medicare to pay for out-of-pocket costs like deductibles and coinsurance, Medigap may still help make insulin more affordable.
These plans are offered by private insurance companies and follow federal standards as well as state-based regulations. Coverages vary based on which Medigap plan you select. However, all plans help cover Part B coinsurance, which could make out-of-pocket costs for Part B-covered insulin treatments and supplies more affordable.
Does Medicare Cover All Insulin Types?
Medicare Part D covers injectable insulin and some types of inhaled insulin. It does not cover insulin delivered with an insulin pump. If you manage your diabetes with an external insulin pump, Medicare Part B may provide coverage. However, it does not cover internal insulin pumps.
Your doctor must prescribe the pump, and you must buy it from a Medicare-approved durable medical equipment supplier or a retail pharmacy working with Medicare.
Part D and Medicare Advantage plans also typically have a list of eligible prescription drugs, called a formulary. When choosing your plan, it’s essential to review the formulary to determine whether the type of insulin you use is covered or if there’s a viable alternative on the list.
How Does Insulin Work and What Is It Needed For?
Insulin is a vital hormone that regulates glucose, or blood sugar, in the body. Individuals with Type I diabetes produce little or no insulin on their own. Those with Type II diabetes do not make or use insulin efficiently. Both conditions can lead to serious health problems if left untreated, including kidney damage, nerve damage, and blindness.
Several insulin-based treatments are available to help manage diabetes. Insulin therapy replaces insulin, helping to keep blood glucose levels within the desired range. For those with type I diabetes, it makes up for the insulin the body does not produce. For those with Type II diabetes, insulin therapy is utilized when other treatments cannot keep blood glucose levels within the desired range.
Insulin is not dispensed as oral medication, such as in a pill, because the digestive system would break it down before it could create the desired effects. Instead, it’s typically delivered through an injection using shots or with an insulin pump that provides small, steady doses of rapid-acting insulin. However, some people with very mild type II diabetes can use diabetes pills to help their bodies produce and manage insulin.
How Much Does Insulin Cost?
The total spending on diabetes treatment in the United States is approximately $237 billion per year. In 2020, aggregate out-of-pocket spending for insulin products among people with Medicare Part D rose to $1.03 billion. The average Part D beneficiary without low-income subsidies pays approximately $572 per year for their insulin treatments, with some paying much more.
Without insurance coverage, costs are significantly higher. Some brands of insulin cost as much as $350 per vial, and many people with diabetes need two vials per month.
How to Save On Insulin With the Senior Savings Model or Medicare Extra Help
You can get multiple types of insulin for a maximum copayment of $35 each month if you join a Medicare Part D plan that participates in the Senior Savings Model. This could also be available through some Medicare Advantage plans. The Senior Savings Model aims to make drug coverage more affordable for beneficiaries.
The $35-per-month copayment applies throughout your drug coverage’s deductible, initial coverage, and coverage gap phases. However, during the final catastrophic coverage phase of your Part D benefit, the $35 copay does not apply. Once you reach this phase, the cost of your insulin and supplies may vary.
Some beneficiaries may also be eligible for Medicare Extra Help. This program helps lower-income beneficiaries afford Part D premiums, coinsurance, deductibles, and other costs. In this case, insulin may cost less than the $35-per-month copay from the Senior Savings Model. Eligibility for Extra Help includes being on full Medicaid coverage, receiving Supplemental Social Security Income, and/or receiving state help paying your Part B premiums.
How Does the Medicare Diabetes Prevention Program Work?
The Medicare Diabetes Prevention Program is a health behavior change program designed to help prevent type II diabetes. It includes 6 months of weekly group sessions that teach beneficiaries realistic strategies for making long-term behavior changes. Methods include information on getting more exercise and controlling your weight. The program gives you access to specialty coaches and a support group of people with similar challenges and goals to help keep you motivated.
To be eligible for the program, you must have Medicare Part B or a Medicare Advantage Plan and a body mass index (BMI) of 25 or higher. You must also have no history of type I or type II diabetes, and never have been diagnosed with end-stage renal disease (ESRD). Within 12 months of your first session, you must also have at least one of the following:
- Fasting plasma glucose of 110 to 125 mg/dL
- Hemoglobin A1c test results between 5.7% and 6.4%
- 2-hour plasma glucose of 140 to 199 mg/dL
There is no charge for eligible individuals to participate in this program. However, it is only offered once per lifetime. If you have previously participated, you cannot access the program for free again.
Locate an approved Medicare Diabetes Prevention Program supplier to enroll in the program. Traditional healthcare providers, faith-based organizations, and community centers may host the program.