Medicare Will Cap Insulin At $35 Per Month, But Is Your Prescription Still Covered By Your Plan? Better Check!

Medicare Will Cap Insulin At $35 Per Month, But Is Your Prescription Still Covered By Your Plan? Better Check!

(Washington, DC) – The recently enacted Inflation Reduction Act requires Medicare Part D plans to cap insulin costs at $35 per month per covered prescription starting in 2023, but to get the savings, diabetic Medicare beneficiaries first need to confirm that their insulin will be covered by their plan next year, warns the Senior Citizens League (TSCL). “If your insulin isn’t covered by your plan, the $35 cap will not apply and you could wind up with thousands of dollars in pharmacy bills,” says Mary Johnson, a Medicare, and Social Security policy analyst for The Senior Citizen League.

“Medicare Advantage and freestanding prescription drug plans make changes to their plans every year and can drop coverage of a drug without informing enrollees of the change in advance,” says Johnson. During Medicare Open Enrollment, underway now through December 7, Medicare beneficiaries can learn about changes to their current plans, confirm coverage of drugs in their current plans, compare options for coverage in 2023, and switch plans if they can find a better match.

For the past 17 years, Johnson has been helping friends and family check and compare their Medicare coverage options during the annual Medicare Open Enrollment Period. “Drug plans don’t send their formularies by mail unless enrollees request a copy,” Johnson says. Even with the list of covered drugs, plans can make changes after the formulary was printed. “Calling the plan’s customer service number is one way to confirm continued coverage of your insulin in 2023, but it requires going through automated menus, getting put on hold, confusing terminology, and a process that can drive up your blood pressure,” says Johnson.

Medicare’s Drug Plan Finder, the online tool that can be useful in helping Medicare beneficiaries verify these details, carries a warning this year — “This new $35 cap may not be reflected when you compare 2023 plans. You should talk to someone for help comparing plans.”  “We absolutely agree that help is needed this year, but many Medicare beneficiaries have no idea where to get experienced assistance with this task,” Johnson says. “Free, unbiased help is available in almost every area of the country. Beneficiaries and other family members can find contact information online through their State Health Insurance Assistance Program (SHIP). Many of these programs operate through local Area Agencies on Aging and can help you over the phone or set up appointments for in-person visits. “Do not put this task off. It is easy when you call and let a Medicare counselor do the work to get you through this,” Johnson says.

Johnson’s first case this Open Enrollment season is a neighbor who is enrolling in Medicare for the first time. He takes 10 prescription drugs, including two types of insulin — Humalog and Lantus. Johnson, who has been doing drug plan searches, immediately hit a dead end on her first search attempt using the Medicare Drug Plan Finder.  The initial results appeared to indicate that no drug plan in their area covered her neighbor’s insulin prescriptions. Even worse, it appeared he might be on the hook for as much as $5,737.39 in premiums and out-of-pocket prescription costs next year. “Something wasn’t right, but I was not sure at first what else to try,” she said.

Johnson tried calling a few drug plans directly to learn more about the insulins that the plans offered on their formularies. “It was horrifying,” says Johnson. The calls took about an hour per call to confirm the prescribed insulins were covered by the plan. One of the plans had customer service representatives who answered questions about drug coverage in Medicare Advantage plans, even though information for free-standing Part D plans was specifically requested. One plan representative only disclosed the fact that she was discussing Medicare Advantage after the first 30 minutes. Even worse, the plan representative never confirmed what insulins the plan covered,” Johnson says. “Another plan put me on hold after every single question but finally confirmed that Lantus at least, would be covered by their plan at $35 per month, even though the Medicare Plan Finder showed the generic version of Lantus was not covered by that plan.

“That call, however, was an ah-ha moment,” said Johnson. “The drug input in the Medicare Drug Plan Finder automatically defaults to the generic name of the drug unless the user overrides it and clicks on “brand.”  “My first search was unsuccessful because I had input the drugs allowing the generic default instead of selecting the brand names,” she said. Johnson re-entered all the drug information and finally located a drug plan that appears to cover all her neighbor’s prescriptions.

Even when the drug plan finder produces the list of drug plan choices, “the real work is just getting started,” Johnson says. Additional effort is required to confirm which plans on the list cover all or at least most of the selected drugs. “Ten prescriptions can be a lot for any Part D plan to cover,” says Johnson. The Drug Plan Finder provides a large amount of detail about whether the drug is covered, what “tier” it appears on in the formulary, and cost, but “this is another point where it helps to have a Medicare counselor along, who knows where to look up this information,” Johnson says. “It’s buried.”

“If your insulin is covered by your drug plan formulary, then by law your insulin cost should be limited to $35 per covered prescription per month,” Johnson says. Johnson was able to find an Anthem drug plan that covered 9 out of 10 of her neighbor’s prescriptions and would cost her neighbor an estimated $2,007.67 in drug costs and premiums versus the $5,737 they found on their first search — still expensive, but big savings over the first attempt.

The only uncovered drug, folic acid, is not usually covered by Part D plans,” Johnson says, “but it costs less than $3 a month from Walmart, CVS, or Walgreens — less than most co-pays.”  “When the top choice of drug plans covers most, but not all, of your drugs, it might still be the best you can do,” Johnson says. “To lower the costs of drugs not covered by your plan, check for discount coupons from Good,” she says.

The last step after selecting a new plan for 2023? Call the number listed for the plan to confirm the drug coverage and cost information for the plan you are thinking about. “No escaping that step,” Johnson says.

If all checks out, Johnson recommends enrolling in the selected plan through the Medicare website, rather than going through the insurance company’s website or by phone. “Enrollment errors are reduced by using the Plan Finder, and for those who are switching from one plan to another, Medicare will make sure you are correctly dis-enrolled from your previous plan,” Johnson says. “Hang on to your Medicare enrollment confirmation paperwork,” she adds. “New enrollees will get their welcome package with their Part D enrollment card and premium payment information within a few weeks,” she adds.


With 1.2 million supporters, The Senior Citizens League is one of the nation’s largest nonpartisan seniors’ groups. Its mission is to promote and assist members and supporters, to educate and alert senior citizens about their rights and freedoms as U.S. Citizens, and to protect and defend the benefits senior citizens have earned and paid for. The Senior Citizens League is a proud affiliate of The Retired Enlisted Association. Visit for more information.