Medicare covers insulin, but your out-of-pocket cost depends on which Medicare plan you have and which insulin product your doctor prescribes.

If you have Original Medicare (Part A and B), insulin is covered as a prescription drug only through Part D, the prescription drug plan you add separately. If you have a Medicare Advantage plan (Part C), that plan covers insulin through its built-in drug benefit. Either way, you will pay something — Medicare does not cover insulin at no cost — but the amount varies widely based on your plan's formulary (the list of drugs it covers) and your stage of coverage.

Starting in 2024, Medicare capped the monthly cost of insulin at $35 per prescription for people in the Part D coverage gap (the "donut hole") and for those who have reached their out-of-pocket maximum. If you are in the initial coverage stage, you may pay less through your plan's copay or coinsurance, or you may pay more if your insulin is not on your plan's preferred list. The key is knowing which plan you are in and what your specific insulin costs under that plan.

Key Takeaways

  • Original Medicare Part D covers insulin as a prescription drug, and you choose and pay for a separate Part D plan.
  • Medicare Advantage plans include drug coverage automatically, so insulin is covered through that plan's formulary.
  • Your out-of-pocket cost for insulin depends on your plan's copay, coinsurance, or whether your insulin is on the plan's preferred drug list.
  • Starting in 2024, your monthly cost for insulin cannot exceed $35 once you reach the coverage gap or meet your out-of-pocket maximum.
  • You can change your Part D plan or Medicare Advantage plan during the annual enrollment period (October 15 to December 7) if your current plan's insulin cost is too high.

How Insulin Coverage Works Under Original Medicare and Part D

If you have Original Medicare, insulin is not covered under Part B (medical insurance). Instead, it is covered as a prescription drug under Part D, which you must enroll in separately through a private insurance company. Part D plans vary in what they cover and how much you pay, so two people on Original Medicare may pay very different amounts for the same insulin.

When you enroll in Part D, you choose from plans offered in your state. Each plan has its own formulary — a list of covered drugs organized by tier. Insulin products are usually on the formulary, but they may be on a higher tier (requiring higher copays or coinsurance) or they may require prior authorization (approval from the plan before you fill the prescription). Some plans prefer certain insulin brands over others, which affects your cost.

Your Part D cost has four stages: the initial coverage stage, the coverage gap, catastrophic coverage, and the out-of-pocket maximum. In the initial stage, you pay a copay or coinsurance for each prescription. Once your total drug costs reach a certain amount (in 2024, that amount is $5,850), you enter the coverage gap, where the $35 monthly cap on insulin applies. Once your out-of-pocket spending reaches $7,050, catastrophic coverage begins and Medicare pays most of the cost.

How Insulin Coverage Works Under Medicare Advantage

Medicare Advantage plans (Part C) include prescription drug coverage as part of the plan, so you do not enroll in a separate Part D plan. The plan's formulary determines which insulins are covered and at what cost. Like Part D, Medicare Advantage plans organize drugs by tier, and your copay or coinsurance depends on which tier your insulin is on.

Medicare Advantage plans also have out-of-pocket maximums, which cap your total spending on covered services (including drugs) in a year. Once you reach that maximum, the plan pays 100 percent of covered costs for the rest of the year. The $35 monthly insulin cap also applies to Medicare Advantage plans once you reach the coverage gap or out-of-pocket maximum, just as it does for Part D.

One advantage of Medicare Advantage is that you see your drug coverage and medical coverage in one place, which can make it easier to understand your total costs. However, Medicare Advantage plans have networks, so you may need to use pharmacies in the plan's network to get the best price on insulin.

What Affects Your Out-of-Pocket Cost for Insulin

Your actual cost for insulin depends on several factors. The first is which insulin your doctor prescribes. Newer insulins (like insulin glargine, insulin lispro, and insulin aspart) are often on higher tiers than older insulins (like NPH insulin), so they may cost more. If your plan does not cover your prescribed insulin on a preferred tier, your doctor may be able to request an exception or switch you to a covered alternative.

The second factor is your plan's tier structure. A copay plan charges a flat fee per prescription (for example, $15 for a generic insulin, $50 for a brand-name insulin). A coinsurance plan charges a percentage of the drug's cost (for example, 25 percent). Copay plans are easier to predict, but coinsurance plans may be cheaper if the drug is expensive. Check your plan's formulary before you enroll to see how your insulin is priced.

The third factor is whether your plan requires prior authorization. Some plans require your doctor to get approval before you fill an insulin prescription. This can delay your prescription by a few days, so ask your doctor's office whether your insulin needs prior authorization and have them request it before you need a refill.

The fourth factor is your pharmacy. Chain pharmacies (CVS, Walgreens, Walmart) and mail-order pharmacies may have different prices for the same insulin under the same plan. Some plans offer lower copays at preferred pharmacies. Ask your plan which pharmacies offer the lowest cost for your insulin.

The $35 Monthly Insulin Cap and How It Works

Starting January 1, 2024, Medicare limits your monthly out-of-pocket cost for insulin to $35 per prescription, but this cap applies only in two situations: when you are in the Part D coverage gap, or when you have reached your out-of-pocket maximum for the year.

In the initial coverage stage (before you reach the coverage gap), you pay your plan's regular copay or coinsurance, which may be less than $35 or more than $35 depending on your plan and your insulin. Once your total drug costs reach $5,850 in 2024, you enter the coverage gap. At that point, your monthly cost for any insulin prescription is capped at $35, no matter what the insulin normally costs.

Once your out-of-pocket spending reaches $7,050 in 2024, you enter catastrophic coverage. At this stage, Medicare pays 80 percent of insulin costs and you pay 20 percent, but your monthly cost for insulin is still capped at $35. This cap applies to all insulins covered by Medicare, including newer and more expensive ones.

Changing Your Plan If Your Insulin Cost Is Too High

If your current Part D or Medicare Advantage plan charges too much for your insulin, you can switch plans during the annual enrollment period, which runs from October 15 to December 7 each year. The new plan takes effect January 1.

Before you switch, use the Medicare Plan Finder tool on Medicare.gov to compare how much your insulin costs under different plans in your area. Enter your insulin name and dosage, and the tool will show you the copay or coinsurance for each plan. You can also call 1-800-MEDICARE to speak with someone who can help you compare plans.

If you have a life-changing event (such as moving to a new state, losing other health coverage, or getting married), you may be able to change plans outside the annual enrollment period through a Special Enrollment Period. Call 1-800-MEDICARE to find out whether you may have access to.

How to Find Out What Your Plan Covers

The best way to know what your insulin costs under your plan is to check your plan's formulary and call your pharmacy. Your plan's formulary is available on the insurance company's website or through Medicare.gov. Look for your insulin by name and dosage, and note which tier it is on and whether it requires prior authorization.

Then call your pharmacy (the one you plan to use) and ask what your copay or coinsurance will be for that insulin under your plan. Pharmacy staff can tell you the exact cost and whether there are any restrictions. If the cost is higher than you expected, ask your pharmacist whether a generic or lower-tier alternative is available, or ask your doctor whether you can switch to a covered insulin.

You can also use the Medicare Plan Finder on Medicare.gov, which lets you enter your medications and see how much they cost under different plans. This tool is updated regularly and can help you compare plans before the annual enrollment period.

Frequently Asked Questions

Does Medicare cover insulin pens and needles?

Medicare Part B covers insulin syringes, needles, and lancets as durable medical equipment if your doctor prescribes them. Part D covers insulin pens and vials as prescription drugs. If you use an insulin pump, Part B covers the pump itself and some supplies, but you may need to use a supplier enrolled in Medicare.

What if my doctor prescribes an insulin that is not on my plan's formulary?

Your doctor can request a formulary exception, asking the plan to cover the insulin even though it is not on the preferred list. The plan usually responds within 72 hours. If the plan denies the exception, you can appeal or ask your doctor to prescribe a covered alternative insulin.

Can I use GoodRx or other discount programs with Medicare?

You cannot use GoodRx or other discount programs at the same time as your Medicare Part D plan — you have to choose one or the other. For most people, Medicare Part D is cheaper, especially once you reach the $35 monthly cap. Ask your pharmacist to compare the price under your Part D plan versus a discount program before you decide.

Does Medicare cover continuous glucose monitors or insulin pumps?

Medicare Part B covers continuous glucose monitors and insulin pumps if your doctor prescribes them and you meet certain criteria. You will need to use a Medicare-approved supplier and may have to pay a copay or coinsurance. Call 1-800-MEDICARE to find approved suppliers in your area.

What happens to my insulin coverage if I switch from Original Medicare to Medicare Advantage?

Your insulin coverage will move from Part D to your Medicare Advantage plan's drug benefit. The cost may be higher or lower depending on the plan's formulary and tier structure. Make sure your insulin is covered under the Medicare Advantage plan before you switch, and check the copay or coinsurance amount.