It’s healthcare open enrollment season, and people on Medicare should be especially aware of potential changes to their insurance plans.
“Plans are dropping insulins,” says Diane Omdahl. Omdahl is a registered nurse and longtime expert in navigating the Medicare system; she co-founded a Medicare consultancy named Sixty-Five Incorporated. “Plans have the option not to cover drugs, and that’s what’s happening. It’s going to be tough.”
Omdahl is urging Medicare recipients who use insulin to check to make sure that all of their medications will be covered next year. Your plan might be dropping your medications from its formulary, and if you reenroll without double-checking, you could find yourself out of luck: “Come January you’ll be locked in for the whole year.”
If your insurance doesn’t pay for the insulin you’re using, it could cost you thousands. High prices can be downright ruinous for many seniors: A 2022 analysis by Yale academics found that nearly 20 percent of Medicare recipients who use insulin reach “catastrophic” levels of spending to pay for their medicine.
That was supposed to change. In the summer of 2022, the U.S. Congress passed the Inflation Reduction Act, which capped the price of insulin at $35 per month for Medicare recipients. But the copay cap, which went into effect last January, is not universal — it applies only to insulins listed on the insurer’s formulary. Not every insurer covers every type of insulin, and insurers can change the medications they cover from one year to the next.
Omdahl believes that insurers are dropping insulins and other medications to compensate for a significantly altered insurance landscape. The Inflation Reduction Act suddenly made insulin a much less profitable product for Medicare insurers. And a deluge of requests for expensive blockbuster drugs like Ozempic and Mounjaro has caused insurers to scramble.
To assess the scope of the changes, Omdahl conducted an informal survey of how 22 Medicare plans plan to cover insulin in 2024. She found that 10 plans, nearly half of them, are dropping at least one insulin from their formulary. Four plans are dropping four or more different insulins.
How to Check Your Coverage
The first thing to do, Omdahl says, is go to Medicare.gov and make a profile. You can input every drug you take and see if your plan will cover those drugs in 2024. You can also see how other plans for which you’re eligible treat the same drugs.
Omdahl advises using the official website if at all possible. Calling in can be a nightmare: “I’ve been hearing that the wait to talk to a rep is two to four hours!”
The time is now, says Omdahl: “Medicare beneficiaries that have diabetes need to take a look at what’s happening before the end of the open enrollment period, which is December 7.”
If your plan is dropping your insulin in 2024, you’ve got a choice: Either change your medication, change your plan, or prepare to spend a lot more money. If changing drugs seems necessary — for example, if you use Levemir, which will be discontinued next year — you almost certainly need to speak to your clinician first.
“You’ve got less than a month now to talk to your doctor and find acceptable substitutes. You need to start yesterday!”