Medicare Plan Finder probably won't notice a new $35 cap on out-of-pocket insulin costs

Medicare Plan Finder probably won't notice a new $35 cap on out-of-pocket insulin costs

A big reduction in prescription drug prices for some Medicare beneficiaries is coming next year, but finding those savings isn't easy.

Congress in August approved a $35 cap on seniors' spending on insulin as part of the Anti-Inflation Act, along with free vaccines and other Medicare improvements. But the change came too late to add Medicare Plan Finder the online tool that helps beneficiaries sort through dozens of drug and health plans for the best bargain.

Officials say the issue only affects 2023 plans.

To address expected enrollment errors, Medicare officials will allow beneficiaries who use insulin to switch plans next year. You can make a change after December 8 and throughout 2023 through a special “exceptional circumstances” filing period. Typically, people are locked up for a whole year.

The Centers for Medicare & Medicaid Services provided initial details of the possibility in a Document distributed for the State health insurance assistance program, or SHIP, which supports Medicare enrollees in every state. Although Medicare has not released the document, beneficiaries can obtain more information by contacting their local SHIP office. CMS officials would not answer questions about whether the ability to change plans is granted automatically.

“We are pleased that CMS is offering the special enrollment period that allows insulin users to change their plans in 2023,” said Chris Reeg, director of the Ohio Senior Health Insurance Information Program.

In some cases, a special enrollment period can be avoided, said Janet Stellmon, director of the Montana State Health Insurance Assistance Program. If the plan requires more than a $35 copay for a member's insulin, a SHIP advisor can ask the plan to correct the error. “Plans usually try to do it quickly,” said Stellmon, who helped one beneficiary save $565 a month on insulin.

Medicare patients spent $1 billion on insulin products in 2020 - four times as much as in 2007, with some paying for it up to $116 per month out of his own pocket, KFF found. Americans paid on average five to ten times According to a recent study in 2018, as much for insulin as in other countries. About 3.3 million people with Medicare rely on one or more insulin products to control blood sugar levels.

The $35 copay for injectable insulin products goes into effect January 1 and July 1 for patients using an insulin pump.

If beneficiaries who use insulin check the plan finder now, the price could be thousands of dollars a year instead of the legal maximum of $420. An inaccurate price could also distort the cost of other medications, which depend on which phase of coverage patients enter. For example, if both the plan and the patient spend a total of $4,660 on all medications next year, the member will pay no more than 25% of the cost of non-insulin medications.

It is extremely difficult for consumers to evaluate policy options without Plan Finder. One plan may have the lowest price for one drug but not another. Or a plan could have the lowest premium but higher drug prices. Or a preferred pharmacy in one plan may be excluded in another.

Medicare officials are warning consumers about the problem. “This new $35 cap may not be reflected when you compare plans,” reads an alert that appears during a Plan Finder search. “You should speak to someone to help you compare plans,” it says, directing readers to the Medicare hotline — 800-633-4227 — or an advisor at SHIP. There is no mention of the ability to change plans after the Dec. 7 enrollment deadline.

But both SHIP advisors and representatives who answer the Medicare hotline rely on the same flawed plan finder.

Georgia Gerdes at AgeOptions in Oak Park, Illinois, trains people across the state to help Medicare beneficiaries. She said she looks for policies without adding insulin to a client's medication list and separately looks for plans that cover the type of insulin the client takes. She then checks these lists to see which ones on the insulin list are also on the non-insulin drug list and manually adds the $35 monthly insulin cost before making recommendations.

According to the KFF study, Medicare beneficiaries filled prescriptions for at least 114 types of insulin in 2020, and those who did not receive low-income subsidies paid an average of $572 out of pocket.

But drug plans don't have to cover all injectable insulins, he said Tatyana Fassieux, an education and training specialist at California Health Advocates. “It’s all about the formulary,” she added, referring to the medications covered by the plans.

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