Medicare covers insulin, but your out-of-pocket cost depends on which part of Medicare you have and which insulin you use

If you have Medicare and take insulin, the program will help pay for it — but not all insulin costs the same amount, and not all insulins are covered equally. Medicare Part B covers insulin syringes and needles. Medicare Part D (prescription drug coverage) covers the insulin itself. If you have Original Medicare without Part D, you pay the full price. If you have a Medicare Advantage plan, insulin coverage is built in, but the drugs covered and your copay amounts vary by plan.

The amount you pay out of pocket depends on which insulin your doctor prescribes, whether it's on your plan's formulary (the list of covered drugs), and what stage of the year you're in. In 2024, Medicare capped the monthly cost of insulin at $35 for people on Part D, but this applies only to covered insulins — and not all insulins may have access to.

Key Takeaways

  • Medicare Part D covers insulin itself; Part B covers syringes and needles, so you need both or a Medicare Advantage plan to have full coverage.
  • Your monthly insulin cost is capped at $35 under Part D in 2024, but only for insulins on your plan's formulary.
  • If your doctor prescribes an insulin not on your plan's list, you can ask for a formulary exception or switch to a covered insulin.
  • Medicare Advantage plans cover insulin as part of their drug benefit, but copays and covered drugs differ between plans.
  • If you cannot afford insulin even with Medicare, patient information programs run by insulin makers offer free or reduced-cost insulin.

How the $35 monthly insulin cap works

Starting in 2024, Medicare Part D limits your out-of-pocket cost for covered insulin to $35 per month, no matter how much the insulin actually costs. This applies to all insulin types — rapid-acting, long-acting, and premixed — as long as the insulin is on your plan's formulary.

The $35 cap applies only after you have paid your deductible (if your plan has one). Once you reach the deductible, you pay no more than $35 per month for a one-month supply of any covered insulin. If you use multiple insulins — for example, a long-acting insulin plus a rapid-acting one — each counts separately, so you could pay $35 for each one.

This cap does not explore to insulin you buy without a prescription or to insulin purchased outside the United States. It also does not cover insulin pens, pumps, or other delivery devices — only the insulin itself and the syringes and needles used to inject it.

What happens if your insulin is not on your plan's formulary

Each Medicare Part D plan maintains a formulary — a list of covered drugs. Not every insulin is on every formulary. If your doctor prescribes an insulin that is not on your plan's list, you have three options: pay the full price out of pocket, ask your doctor to prescribe a different insulin that is covered, or request a formulary exception.

A formulary exception is a request to your plan to cover a drug that is not on the formulary. You or your doctor can submit this request. Plans often approve exceptions when the covered alternatives have not worked for you or when your doctor documents a medical reason why you need the specific insulin. The exception process usually takes a few business days, though urgent requests can be faster.

If the exception is denied, you can appeal. Your plan must tell you how to appeal and give you at least 60 days to do so. During the appeal, you can ask your doctor to provide additional medical information supporting the need for that specific insulin.

Medicare Advantage plans and insulin coverage

If you have a Medicare Advantage plan (Part C), insulin coverage is included as part of the plan's drug benefit. You do not need to enroll in a separate Part D plan. However, each Medicare Advantage plan sets its own copay amounts, deductibles, and formulary, so the cost of your insulin depends on which plan you have.

Some Medicare Advantage plans also cap insulin at $35 per month, while others may charge a different copay. When you enroll in a Medicare Advantage plan or during the annual open enrollment period, you can review the plan's formulary to see which insulins are covered and what your copay will be.

If you switch Medicare Advantage plans, your insulin coverage may change. Before switching, check whether your current insulin is covered under the new plan and what the copay will be.

Original Medicare without Part D: what you pay

If you have Original Medicare (Part A and Part B) but no Part D coverage, Medicare Part B covers insulin syringes and needles, but the insulin itself is not covered. You pay the full retail price for insulin, which can range from $100 to $300 or more per month depending on the type and brand.

If you are in this situation, you have several options. You can enroll in a Part D plan during the annual open enrollment period (October 15 to December 7 each year) or during a special enrollment period if you have a may have access to life event. You can also look into patient information programs run by insulin manufacturers, which may provide insulin at no cost or reduced cost based on your income.

Patient information programs when Medicare coverage is not enough

If you cannot afford insulin even with Medicare coverage, the companies that make insulin offer patient information programs. These programs provide insulin at no cost or reduced cost to people who meet income requirements. The major insulin makers — Eli Lilly, Novo Nordisk, and Sanofi — all run these programs.

To find out whether you are may be able to access, contact the insulin maker directly or visit their website. You will typically need to provide proof of income and proof that you have Medicare. The process process usually takes one to two weeks. Some programs deliver insulin directly to your home.

You can also contact 211 (dial 2-1-1 or visit 211.org) to find local programs that help with medication costs in your area.

How to review your insulin coverage before open enrollment

If you have Medicare Part D or a Medicare Advantage plan, you can review your insulin coverage right now at Medicare.gov. Log in to your account, go to "My Health Care," and select your plan. You will see your plan's formulary, which lists all covered drugs and the copay for each one.

If you are thinking about switching plans during open enrollment, compare the insulin coverage in your current plan with the coverage in plans you are considering. Look at the copay amount, whether your specific insulin is covered, and whether there is a deductible you have to meet before coverage starts.

If you have questions about your coverage or need help understanding your plan's formulary, you can call Medicare at 1-800-MEDICARE (1-800-633-4227). Representatives are available 24 hours a day, seven days a week.

Frequently Asked Questions

Does Medicare cover insulin pumps and continuous glucose monitors?

Medicare Part B covers insulin pumps and the supplies that go with them (tubing, infusion sets, reservoirs) if your doctor prescribes them and you meet certain medical criteria. Continuous glucose monitors are also covered by Part B. However, coverage rules and copay amounts vary, so check with your plan about what you will pay out of pocket.

What if I use insulin that costs more than $35 per month?

If your insulin normally costs more than $35 per month, you still pay only $35 under the Part D cap. Your plan and the pharmacy handle the difference. You do not have to do anything special — the $35 cap applies automatically at the pharmacy counter when you pick up a covered insulin.

Can I use GoodRx or other discount programs with Medicare?

You can use discount programs like GoodRx, but only if you are not using your Medicare coverage at the same time. If you use GoodRx, the cost does not count toward your Part D deductible or out-of-pocket maximum. In most cases, the $35 Medicare cap is a better deal than a discount card, so compare prices before you choose.

What happens to my insulin coverage if I move to a different state?

Your Medicare coverage travels with you, but your specific Part D plan may not be available in your new state. If you move, you have a special enrollment period to switch to a plan that is available where you now live. Contact Medicare or your current plan to find out what plans are available in your new location.

Do I have to pay for insulin during the donut hole?

The "donut hole" is a coverage gap in Part D that used to require you to pay more for drugs. As of 2024, the donut hole has been eliminated for insulin — you continue to pay only $35 per month for covered insulin even after you have spent a certain amount on drugs during the year.