Medicare Caps Copay for Insulin at $35 per Month

As most of you (and your Medicare patients) have undoubtedly noticed, Medicare has applied a $35 per month cap on copays for insulin prescriptions ($105 for a 3-month supply) for years 2023-2025. For 2026 and beyond, copays will be capped at the lesser of $35 or 25% of the negotiated price.

Section 11406 of the Inflation Reduction Act of 2022 implemented this cap for Medicare Part D and Medicare Advantage patients effective January 1, 2023, while Section 11407 requires implementation for Medicare B covered insulin as of July 1, 2023.

Plan Sponsors have a 90-day grace period to implement these copay caps and any excess copays calculated at adjudication must be refunded by the plan.

PAAS Tips:

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

  • The definition of “one month” varies by plans
  • Pharmacies should collect the full copay amount as per online adjudication and advise patients that the plan will refund patients for any amounts in excess of $35 per month
  • Pharmacies should be extra diligent when calculating days’ supply and make sure you have mathematical instructions that support the days’ supply adjudicated
  • See the Insulin Medication chart and Can You Bill It As 30 Days? tool on the PAAS Member Portal for additional guidance
  • The CMS has created the following resources for Medicare patients
    • 7 Things to Know about Medicare Insulin Costs
    • Frequently Asked Questions About Medicare Insulin Cost-Sharing Changes in the Prescription Drug Law

Eric Hartkopf, PharmD