Insulin Costs and Coverage in Medicare Part D

Beginning January 1, 2021, CMS is testing a change where Part D sponsors that participate in the new Medicare Innovation Center model offer beneficiaries prescription drug plans that provide supplemental benefits for insulin in the coverage gap phase of the Part D benefit. Participating pharmaceutical manufacturers will pay the 70 percent discount in the coverage gap for the insulins that are included in the Model, but those manufacturer discount payments would now be calculated before the application of supplemental benefits under the Model.

Part D sponsors participating in the Model will offer beneficiaries plan choices that provide broad access to multiple types of insulin, marketed by Model-participating pharmaceutical manufacturers, at a maximum $35 copay for a 30-days’ supply in the deductible, initial coverage, and coverage gap phases of the Part D benefit. As a result, beneficiaries who take insulin and enroll in a plan participating in the Model should save an average of $446 in annual out-of-pocket costs on insulin, or over 66 percent, relative to their average cost-sharing today. This predictable copay will provide improved access to and affordability of insulin in order to improve management of beneficiaries who require insulin as part of their care.

Walmart’s ReliOn Insulin

The over-the-counter insulin from Walmart that costs about $25 per vial is limited to two types of insulin:

  • Regular (insulin R)
  • NPH (insulin N)

You can also get a premixed combination of NPH and Regular called 70-30. 

Both of these insulins are what’s called “synthetic human insulin”. It’s different from newer insulins that are called insulin analogs. You do not need a prescription to purchase however must go to pharmacy counter.

Medicare Part D (prescription drug coverage)

Part D prescription drug coverage is a way to cover the cost of your prescription drugs and is available through private health insurance companies. Medicare prescription drug coverage is offered through Medicare Advantage plans that include both health care and prescription drug coverage. Medicare Part D is available for eligible participants who are qualified in Medicare Part A and or enrolled in Medicare Part B.

Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.