2021 Insulin $35 monthly copay with medicare

Hello community of experts. . .

I dropped the ball on this topic and not up to date.

I am T1 with 11 yr old out of warranty T-slim pump not in use doing MDI at the moment and playing catchup. Poor control I am embarrassed to admit.

Pharmacist said can’t verify the new $35/month and until putting new script through. Several said never heard of it and do insulin script every day. I am going there shortly to drop off a new script and we’ll see in a couple of days when it’s ready.

By tonight I am completely out of insulin and have to figure out something immediately.

My copay had been running over a grand per month. Called my insurance company today and held for 3 hours to ask, then call got disconnected. Called back and held for over another hour before I hung up.

In other news. . . two years ago I D/C’d insulin pump use after giving up on finding anybody near me or by mail to fill insulin scripts under part B for use in a pump. Initially I had a place doing it then they stopped. To my knowledge nobody is doing it in my State (Florida) despite people here saying they get it that way. That’s a side bar issue.

I can always use the OTC cheap R from WulMurt for a day or two. My insurance is an advantage plan. My concern is that maybe I have to “opt in” or some other gotchya snag which I likely scr*wed up to get the $35 copay.

I just hope this works out smoothly for those of us who end up in the donut hole the first week of each new year.

Insulin for $35/mon copay seems like the impossible dream.

What’s the deal?

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I have Medicare Advantage and in 2020 I was paying a $40 co-pay for a three month supply (9 vials) at CareMark. I just placed a reorder today and was advised the estimated cost would be $40.

Talk to the pharmacist. Not sure if it could apply to you, but my pharmacists know me, know my history, so at times have cut me slack in between prescriptions if I ran short for some reason…

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Here are details.

Seems to apply to Medicare Part D.

If using pump, usually cheaper as Part B, but I think you can choose Part D and get $35 price.

Likely to be confusion by pharmacies, and whether their billing systems are updated.

Complete scam to me. I just looked at it and would require a more expensive part d plan. When I factor in the cost of the extra premium it’s actually cheaper for me to
stay on the part d plan I have now. With the new $35 scam it would cost around $1000 and without around $700. What a useless pile of crap.

Not sure I understand your situation. If you have a Part D plan, it would be $35. If there is deductible, doesn’t matter.

Importantly, this new Medicare $35 cap impacts all of these coverage stages, meaning patients will not be required to pay the large deductible first, or the often higher costs experienced during the “donut hole” stage.

This chart from CMS breaks it down nicely, showing even if you have Part D deductable, it doesn’t need to met for the $35 price. Note the right hand side.

Certainly you may have a case where Part B is better than $35.

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Image via CMS.gov

How much do you pay for your Part D? I just paid my Part D premium today for the full year and the total premium was $194.40 so the $35 monthly insulin cap would be a substantial saving. I will, however, keep buying my insulin out-of-pocket as the formulary on my Part D is Novolog and I have always preferred using Humalog so can afford and am willing to pay the difference to stay with Humalog. Maybe you should just find a lower-priced Medicare Part D insurance during the next open enrollment period.

Now is not the time to look at your Medicare Part D insurance plan. Not doing your research during the open enrolment period, does not a scam make!!! That is on you.

I’m the opposite. I prefer novolog, and last year my insurance switched to humalog.

However, I found a “cash pay” alternative to get $99 novolog for up to 3 vials. But that likely ended year end, hoping to see if new offer is available.

I have a part C plan which means an advantage plan. That also means I have part A,B and D. My insurer is United Healthcare and I am in Florida. And specifically for the $35 per month insulins, I am in, and one must be in or get excluded, what they call a senior savings model which means that no deductibles apply for getting the so-called $35 benefit any time of the year, donut hole or not. But when the pharmacy put through my script apparently, they told me, since I have been a pump user historically, any new script they see for my insulin in 10mL vials they process as of now under part B not part D meaning my 20% copay is many hundreds more than merely $35 a month. I cannot verify this but it is what I was told today. This is hard for me to believe but apparently if I am scripted for Kwickpens then the insurer automatically puts the copay under my part D and there’s no confusion with part B.

In the past we all wanted insulin under part B because it was less copay than under D but not with the $35 a month plan it is just the reverse. I can use any insulins by any route. I couldn’t care less about staying with a pump. I just need the insulin. I know how to best use all of them and various combinations. Anything is better than the OTC R or N by Relion brand sold cheaply at WulMurt. That’s a familiar fall-back plan out of desperation for pumpers who run out of Novolog or Humalog in 10mL vials regardless of the concentrations. For that matter, i can get Kwickpen insulin into a pump if necessary and adjust for the concentration if the Kwickpens are U-200 by using half the dose volume to equate to the U-100 even though we are told not to do this.

Long story short, Kwickpens may (or most likely if not definitely) come under the $35 plan now but vial may not for prior pumpers.

More confusing, apparently insulin lispro (humalog) is covered as U-100 but not U-200, they told me (although I cannot verify) under a part D $35 copay but for Lyumjev the $35 monthly cost applies to any amount of either U-100 or U-200 per month. Makes no sense to me why that is so but let’s presume it is since I was told so by Optim-Rx which is the mail order arm used by United (and maybe others).

As an additional aside, Lyumjev comes in U-100 and U-200. But I am not familiar with it. I never used it. I presume it is new or newer.

The bottom line remains paying as little as possible for insulin(s) by high-dose T1 people like me.

i have no preference for novolog or humalog because in my experience they are unit per unit interchangeable at any dose level used per day. There may be a tiny difference in an amino acid or some branching molecule (like some OH group or a double bonded oxygen keytone attached here vs there on some carbon atom in the 3-d molecule). I haven’t looked at the stereochemistry of the molecules recently and forgot. But in me i detect no difference.

If some med is not in your insurer’s formulary you can still try to have them cover it by getting a prior authorization. This topic has come up before around here. I would merely use the one that’s covered. I make no assertion if an appeal, if necessary is likely to prevail but i begin by doubting it.

i wrote a long reply on this point you made today.

The pharmacist is swamped, barely cares, and has no authority. They will not bend like in the past. Yes, i need a new pharmacy. But I actually do not fault the people working there. It’s policy now and unless you go to an independent then, well. . . don’t expect anything but the rule book.

The chances of getting approval is next to none as this is for the medicare monthly $35 maximum Insulin payment plan which is currently in Beta. Furthermore, even if it was approved, there would be too much risk of the pharmacy running out as cartridge insulin is not yet very popular in the US and lastly my time is worth a heck of a lot more than the few $100 per year savings going through the process even if there were no issues along the way.