The Model aims to reduce Medicare expenditures while preserving or enhancing quality of care for beneficiaries. The Model does not change cost sharing in the catastrophic phase. The Model does this by offering supplemental benefits that apply after manufacturers provide a discounted price for a broad range of insulins included in the Model. Model OverviewĬMS is testing a change to the Medicare Coverage Gap Discount Program (the “discount program”) to allow participating Part D sponsors, through eligible enhanced alternative Prescription Drug plans (PDPs) or Medicare Advantage Prescription Drug plans (MA-PDs), to offer a Part D benefit design that includes stable, predictable copays for select insulins (no more than $35 per prescription for the month's supply) in the deductible, initial coverage, and coverage gap phases. The Centers for Medicare & Medicaid Services (CMS) Part D Senior Savings Model (or the “Model”) was designed to provide Medicare beneficiaries with new choices of Part D plans that offer insulin at an affordable and predictable cost where a one-month supply of a broad set of plan-formulary insulins costs no more than $35 each.ĭetails on pharmaceutical manufacturer and Part D sponsor Model participation can be found below. Unfortunately, sometimes the cost of insulin can be a barrier to appropriate medical management of diabetes. For some of these beneficiaries, access to insulin can be a critical component of their medical management, with gaps in access increasing risk of serious complications, ranging from vision loss to kidney failure to amputation to heart attacks.
One in every three Medicare beneficiaries has diabetes, and over 3.3 million Medicare beneficiaries use one or more of the common forms of insulin.
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