High-Priced Stand-alone PDPs Dominate 2021 Insulin Demo

As Medicare Advantage and Part D sponsors started promoting their offerings during the 2021 Annual Election Period that began on Oct. 15, several major insurers notably mentioned their participation in the first year of the CMS Part D Senior Savings Model (SSM). Perhaps the Trump administration’s most tangible action on insulin costs, the model is intended to reduce Medicare expenditures and improve care quality, but the expense to seniors will vary by plan type and region, according to two consulting firms.

Introduced through the CMS Center for Medicare & Medicaid Innovation (CMMI) in March, the five-year model is intended to lower out-of-pocket costs for diabetic seniors by featuring “predictable” copayments of no more than $35 for a broad set of insulins beginning in 2021 (RMA 3/19/20, p. 1). Specifically, the model will test a change to the Manufacturer Coverage Gap Discount Program by waiving current rules for supplemental benefits used to reduce cost sharing in the coverage gap and enabling Part D sponsors to offer enhanced alternative plan benefit packages (PBPs) that feature standard copays through all phases of the Part D benefit up to catastrophic coverage — instead of cost sharing that changes based on the benefit phase.

© 2024 MMIT
Lauren Flynn Kelly

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.

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