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.

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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

Author
Recent Posts

Eric Hartkopf, PharmD

Analyst at PAAS National^®

As an Analyst, I focus on providing pre- and post-audit assistance, answering various member service questions, and researching & drafting articles for the Third-Party Newsline. I work with many of our members involved with invoice audits.

I obtained my PharmD from the University of Wisconsin-Madison School of Pharmacy and worked for a major chain as well as various LTC and independent pharmacies, before coming to PAAS.

I am passionate about learning and teaching. I strive to learn something new about PBM audits every day, so that PAAS can be more knowledgeable to better serve our members! In 2018, I started traveling to state pharmacy conferences to present audit seminars and meet our wonderful members in person.

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