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.

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