Do you have Diabetes, use Insulin, and are on Medicare?

If the answer is yes, and you’re paying more than $35 a month for insulin, keep reading….

In 2021, Medicare introduced a pilot program called the Senior Saving Model  (SSM) with the aim of reducing the cost of insulin to people on Medicare and improving the quality of their health care.

Who is eligible for this discounted insulin program?

  • People that have diabetes and are prescribed insulin
  • People that are enrolled in Medicare Advantage (MA-PD) plans or Medicare Prescription Drug Plans (PDP) that agreed to participates in the SSM.
  • People that take insulin from manufacturers that participates in the SSM.

What insurance companies and plans participate in the SSM?

There are a variety of insurance companies that sell Medicare Advantage (MA-PD) and stand-alone Prescription Drug Plans (PDP) ranging from large for-profits such as United HealthCare, Humana & CVS to regional non-profits such as BCBS affiliates to small plans with limited subscribers.

To illustrate, in Rochester, NY with a metropolitan population of over 1 million, there are 22 Medicare Advantage plans offered by 5 major insurers: Excellus (BCBS), MVP, CVS/Aetna, United HealthCare, and Wellcare. These insurers sell 22 different MA plans, however, only 4 plans from Excellus and 4 plans United HealthCare participates in the $35/mo. insulin SSM program.

In addition, there are 19 prescription drug plans (PDP) offered in Rochester to individuals that choose to enroll in either Original Medicare or a Medigap plan. Not all PDP insurers participate in the SSM program and not all of their plans include the $35/mo. insulin.

Some insurers offer discounted insulin in their plans with higher monthly premiums. So, you need to carefully evaluate the total cost of each plan including the premium, deductibles, and the price of your prescriptions, with and without the discounted insulin. A plan with discounted insulin may not be the lowest total cost plan when you include the total costs of the plan and all of your medications.

What Insulin brands participate in the SSM program?

Insurers that participate in the SSM program are required to include at least one vial and one pen dosage form for each of the different types of Model insulins, where available and including – rapid acting, short-acting, intermediate-acting and long-acting – all for at a maximum $35 copay for a one-month supply.

Participating Insulin Manufacturers include:

  1. Eli Lilly and Company
  2. MannKind Corporation
  3. Mylan Specialty L.P.
  4. Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
  5. Sanofi-Aventis U.S. LLC

How can you find out if your current plan or other plans available to you, participates in the $35/mo. SSM program and what specific insulins are included?

  • Call your plan’s member services (number is listed on the back of your card)
  • Ask your pharmacist
  • Call & ask Medicare at 800-633-4227
  • Check online at 

With the online, after you input all your medications, you will see an estimate of your total annual out-of-pocket expenses for each plan that you are considering, and for each of your medications and the pharmacy that you select.

Please keep in mind, the Medicare Open Enrollment period end on December 7th, for changes in MA-PD and PDPs that will become effective January 1,2022.

Best wishes

Medicare Plans Offer New Discounted Insulin Prices, or Do They?

Medicare Prescription Drug Plans that are sold by private insurance companies in Medicare Advantage Plans and stand-alone Part D plans for people with Original Medicare and Medigap plans are funded largely under contracts with the federal government using taxpayers funds.

Here’s are 3 things in the fine print you need to know.

1. The new pre-election announcement of a “Part D Senior Saving Program” that lowers your out-of-pocket co-payments for insulin, doesn’t begin until January 1, 2021 and doesn’t include the millions of Americans who use insulin every day but are not on Medicare.

2. The progam is optional for government-funded Medicare plans to participate in and the specific insulin that your doctor prescribes for you may not be included in the plan that you select.

To illustrate, in the upstate NY, we have 30 Medicare Advantage plans offered by 5 different insurers. However, in reviewing the details of their plans, only Excellus BCBS and United Healthcare have chosen to participate in this special option that will benefit seniors and disabled people who need insulin to live.

The other insurers who sell federally subsidized Medicare plans but chose not to participate in this insulin option include: Aetna, Wellcare and MVP (a regional insurer).

In drilling down deeper into the participating plans of Excellus and United Healthcare, a few other differences were noted.

Excellus: offers 5 Medicare Advantage plan that have monthly premiums ranging from $0 to $255. However only the three of the higher prices plans ($79, $157 & $255/mo.) are participating in the savings program. The two plans with either $0 or $39 monthly premiums are excluded.

So, individuals who enroll in a $0 or $39 monthly premium plan will be subject to a $380 or $300 deductible and a $42 a month/ $84 for three month supply of insulin from a preferred pharmacy.

By comparison, individuals who enroll in one of the three higher priced Excellus plans will not be subject to a deductible and will pay $25 a month/ $60 for 3 month supply of insulin from a preferred pharmacy.

United Healthcare: offers 4 plans with monthly premiums ranging from $0 to $79 a month. All of their plans include the insulin saving plan with an insulin cost of $35 a month/$95 for 3 months from a preferred pharmacy until you enter the catastrophic phase of medication expenses.

Finally note….always confirm that all your health care providers participate in any health insurance plan you are considering and that the medications that your doctor and you feel work best for you are also included in the plan’s formulary.

And, don’t be distracted with the marketing of $0 premium plans and extra free benefits that you may never qualify for or use. Spend some time shopping and comparing plans based on your most critical health care needs and the cost you’re likely to experience in the coming year.

There are two common problems that I see with clients….some are gamblers and they are under-insured even when they can afford to be safer.

And there are others that are too complacent and continue to stay with the same insurer/plan for 10 plus years even when their needs and income have changed. They are spending too much on insurance and don’t have enough money for other basic needs.

Look at the options that are available to you and make a choice that allows you to sleep at night.

Best wishes and stay safe and well.

Jim Sorrentino