Since last open enrollment, there have been a number of changes that affect Medicare and type 1 diabetes (T1D). Here is a summary of these changes so you can keep them in mind as you think about Open Enrollment this year.
More CGMs covered
In March 2022, Medicare began to cover any CGM that works with an insulin pump or is labeled to be able to dose insulin. For more information, see our blog post from that time: https://www.jdrf.org/blog/2022/03/10/more-cgms-now-covered-by-medicare/ People with Medicare coverage and T1D now can choose from nearly all FDA-approved CGMs to measure their blood glucose levels. Increased choice makes it easier to use the CGM that works best for your particular needs.
All AP systems covered
Currently, there are three artificial pancreas systems that have FDA clearance and Medicare coverage: Insulet Omnipod 5, Medtronic 670G/770G and Tandem Control IQ. Historically, this has not always been the case. When Medicare expanded coverage of CGMs in 2021, it also expanded coverage to include the Medtronic 670G and 770G, so now all AP systems are covered by Medicare for people with T1D.
$35 Insulin in Both Part B and Part D and Medicare Advantage
Starting in January 2023, Part D covered insulins will cost no more than $35 per month per insulin at the pharmacy counter or mail-order checkout. For tubed pump users who get their insulin through Part B, the $35 out-of-pocket cap will go into effect on July 1, 2023.
Medicare Advantage (MA) and Part D plans can still limit coverage to certain brands of insulin, however they must cover at least one of each type of insulin (long-acting, rapid-acting, etc) and in the different delivery forms (vials, pens, etc).
While the out-of-pocket cost of insulin has been capped at $35 for both Part B and Part D, most Part D or MA plans will NOT reflect this cap when shopping for a plan. Unfortunately, this means that cost estimations from the Medicare Plan Finder will not be accurate for insulin. CMS has recommended when adding drugs to the cost estimator, do not include insulin and instead add $420 (or $840 if you use two types of insulin) to the estimated cost of that plan. They then recommend adding the insulin to the cost estimator to ensure that your plan covers your particular insulin.
When January 2023 rolls around, it is very possible that many MA and Part D plans will not have fully implemented the $35 out of pocket cap at the pharmacy checkout. If this is the case, the plan must refund any overpayment that you make at checkout within 30 days. This will be in effect for January 1, 2023-March 31, 2023. After that time, Part D plans are expected to have made the necessary changes to their internal systems to allow for the $35 cap to be implemented at the point of sale.
Deductibles won’t apply for covered insulins for Part D starting January 1 and Part B starting July 1, 2023. This means that you will only pay the copay for your insulin, and the amount paid will count toward your deductible. Keep in mind that your CGM, test strips, insulin pump or supplies will still be subject to the deductible, which is $226 for Part B and a maximum of $505 for Part D plans.
By 2025, Out of Pocket Cap on Part D of $2000
Looking forward, there will be more changes coming to Medicare Part D in 2024 and 2025. In 2024, Part D plans will have to cap overall out of pocket costs at $3250 and in 2025, the out of pocket cap will be $2000 and can be spread throughout the year. These changes are additional to the 2023 changes to coverage for insulin.
Shopping for Medicare plans can be complicated, especially when you have a chronic condition like T1D. With many welcome changes coming to insulin coverage in 2023, it is critical that you understand the changes and how they could impact your plan shopping.