If you have diabetes, you likely pay twice as much for health care each year as someone who doesn’t. So lowering your out-of-pocket costs becomes a top priority.
What are out-of-pocket costs? Those are all the costs your Medicare insurance plans don’t pay, whatever plans you have. For example, costs could result from deductibles (what you spend before your plan kicks in), copays or coinsurance.
Original Medicare
Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance). But it does not give you prescription drug coverage, so you will want to buy a private Medicare Part D (prescription drug) policy.
Part B doesn’t cover insulin unless it’s used with an insulin pump. Still, it usually pays for blood sugar monitoring supplies (such as blood sugar monitors, test strips and lancets), therapeutic continuous glucose monitors, diabetic test supplies (such as test strips), lancet devices, lancets and glucose control solutions.
Many are covered as “durable medical equipment” (DME) with your doctor’s prescription as long as your doctors and DME suppliers are enrolled in Medicare.[1]
Suppose you have one or more risk factors for diabetes (such as obesity, family history or high triglyceride or cholesterol levels). In that case, Medicare Part B will pay for up to two screenings per year as long as you use a Medicare-assigned provider.
Remember that Medicare Part B only pays 80% of Medicare-approved costs unless you have a Medicare Supplement Insurance (Medigap) policy to help with the rest.
Part D covers you for your insulin and medications within the constraints of your plan. Insulin must be injectable and not administered through an insulin pump or infusion. (Exception: Part B may cover an insulin pump if your doctor prescribes one, but it will be covered as “durable medical equipment.”)
You will need supplies to inject insulin, including syringes, needles, alcohol swabs, gauze and inhaled insulin devices. These costs would be partly covered by Medicare Part D.
Determine with your doctor the most cost-effective options for your needs. Once you define your product needs, shop for a Part D plan whose formulary, or drug list, includes them at the lowest cost. You can change Part D policies each year, should your product needs change.
Medicare Part C
Medicare Advantage (Part C) plans must cover everything Original Medicare covers. But prescription drug coverage is likely included, too. So again, with your doctor, determine the most cost-effective insulin and medications that meet your diabetes-related needs, plus all ancillary supplies. Then choose a Medicare Advantage plan with the best prices and conditions.
You can change your plan each year if your insulin and medication needs change.
Five ways to save on diabetes-related costs
Insulin savings. After January 1, 2021, many types of insulin may be available to you for no more than $35 for a 30-day supply through Medicare drug coverage. The Part D Senior Savings Model is being tested in Medicare Part D and Medicare Advantage plans that participate in the insulin savings model to reduce out-of-pocket spending on insulin for eligible seniors.[2]
Takeaway action step: Call 1-800-MEDICARE to ask about enrollment and eligibility.
Generics. The generic version of name-brand medications can save 50% to 75% and be as effective. The same holds for insulin. Also, medications are categorized into “tiers” in a plan’s formulary: the lower the tier, the lower the price. Generic medicines are usually on lower tiers and have a lower out-of-pocket cost.
Takeaway action step: Ask your doctor to recommend generic products to meet your health care needs.
Online pharmacies. Insurance plan providers align themselves with chains of retail and online pharmacies. And online pharmacies are often less expensive, whether you are buying diabetes-related supplies or insulin.
Takeaway action step: Identify well-known, Medicare-approved online pharmacies and see if they are an alternative, even for insulin (which they will ship cold).
Pharmacy assistance programs. You will find that many drug manufacturers have programs to help patients afford their products. While the programs can lower your out-of-pocket cost-sharing, these purchases may not count towards your plan’s yearly deductible.
Takeaway action step: Once you have identified your necessary insulin and medications, contact the pharmaceutical manufacturer to see if they can help you with the cost.
Extra Help. If you have limited resources, this federal program helps you pay Medicare prescription drug out-of-pocket costs such as premiums, copays and coinsurance.
Takeaway action step: Call 1-800-MEDICARE to ask how much help you are eligible for, then check to be sure that would be less than your other options. Also, ask your drug plan to confirm which option is best.
Wrapping up, if you are the one-in-three Medicare beneficiaries who have diabetes, you know what an expensive condition it can be to treat. One or more of these tools may help lower your out-of-pocket cost of treatment.
[1] Centers for Medicare & Medicaid Services. “Blood sugar monitors.” medicare.gov (accessed March 2, 2022).
[2] Centers for Medicare & Medicaid Services. “Part D Senior Savings Model (Insulin Savings) Common Questions & Answers.” cms.gov (accessed March 2, 2022).