These are the amounts you pay for your covered drugs after the deductible (if the plan has one). You pay your share and your plan pays its share for covered drugs. If you pay coinsurance, these amounts may vary because drug plans and manufacturers can change what they charge at any time throughout the year. The amount you pay will also depend on the tier level assigned to your drug.
Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug, but you keep taking the brand name drug.
Here’s a video about how drug costs can differ by pharmacy.
Under the standard drug benefit, if your out-of-pocket spending on prescription drugs reaches $2,000 in 2025, you pay no further copayments or coinsurance for the rest of the year. For 2024, if your out-of-pocket spending on drugs (including deductible) reaches $5,030, you’ll pay no more than 25% of the cost for prescription drugs until your out-of-pocket spending (including certain payments made on your behalf, like through the Extra Help program) is $8,000.
What if I want to get less than a one-month supply of a drug?
How does this affect my coverage?
Can my Medicare Part D plan remove insulin products from their list of covered drugs during the year? Or add restrictions, like prior authorization or step therapy?
Your plan can change their list of covered drugs (formulary) for specific reasons during the year. Your plan can make changes like:
- Adding or removing drugs
- Placing a drug in a lower cost-sharing level
- Replacing a brand-name drug with a generic drug
- Removing utilization management requirements
In general, your plan must notify you at least 30 days before the cost or coverage of your drug changes.
Are other types of (non-insulin) prescription drugs that I take to manage diabetes included in the monthly $35 cap?
No.
How will my disposable “patch” pump be covered?
If you use an insulin patch pump, you’ll continue to get your insulin through your Part D plan, and the insulin that goes into your pump won’t cost more than $35 a month. Your disposable pump can be covered under Part D as an insulin supply, but because the disposable pump is a supply (and not a drug), the cost for the pump isn’t capped at $35.
How does this affect my costs?
Will I be charged $35 if I get Extra Help?
No, you'll be charged less. People with Extra Help already have lower cost-sharing for insulin, and will continue to pay the lower amounts.
Will my costs be the same at both preferred and non-preferred pharmacies covered by my drug plan?
Yes. You’ll pay $35 (or less) for a month’s supply of a covered insulin product at any in-network pharmacy covered by your drug plan.
How can I estimate what insulin costs count toward my out-of-pocket costs? What about my Part D deductible?
Using your secure Medicare account, you can add your insulin products to your drug list and compare plans. Your $35 (or less) copayment for a month’s supply of each insulin product counts toward your TrOOP. The amount you would have paid (above the $35 cap) for a covered insulin product will also count toward your out-of-pocket costs. Before you meet your Part D deductible, your $35 (or less) copayment will be applied to your deductible.
Does the $35 cap apply across all phases of prescription drug coverage?
Yes. In 2024, once you reach the catastrophic coverage phase, you pay nothing for Part D drugs covered by your plan, including insulin.
How can I estimate when I’ll move through the coverage phases in Medicare Part D?
Using your secure Medicare account, you can add your insulin products to your drug list and compare plans. The coverage phase details will show accurate estimates, including the fact that the amount you would have paid (above the $35 cap) for a covered insulin product will also count toward your progression through the Part D coverage phases.