Part D Senior Savings Model

On January 1, 2022, the second performance year of the Model began, with over 500 new Part D plans participating in the Part D Senior Savings Model. See CY 2022 Model Participation section below for additional information.

Note for people with Medicare: Visit Medicare.gov to find information on how you can get insulin savings through the Part D Senior Savings Model, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Through the Part D Senior Savings Model (or the “Model”), the Centers for Medicare & Medicaid Services (CMS) is testing the impact of offering beneficiaries an increased choice of enhanced alternative Part D plan options that offer lower out-of-pocket costs for insulin. The voluntary Model began on January 1, 2021, and will continue for five years, through December 31, 2025. The Model’s test contributes to the modernization of the Part D benefit and enhanced access to prescription drugs for Medicare beneficiaries.

Background

One in every three Medicare beneficiaries has diabetes, and over 3.3 million Medicare beneficiaries use one or more of the common forms of insulin. For some of these beneficiaries, access to insulin can be a critical component of their medical management, with gaps in access increasing risk of serious complications, ranging from vision loss to kidney failure to amputation to heart attacks. Unfortunately, sometimes the cost of insulin can be a barrier to appropriate medical management of diabetes.

The Centers for Medicare & Medicaid Services (CMS) Part D Senior Savings Model (or the “Model”) is designed to provide Medicare beneficiaries with new choices of Part D plans that offer insulin at an affordable and predictable cost where a one-month supply of a broad set of plan-formulary insulins costs no more than $35 each.

Details on pharmaceutical manufacturer and Part D sponsor Model participation can be found below.

Model Overview

CMS is testing a change to the Medicare Coverage Gap Discount Program (the “discount program”) to allow participating Part D sponsors, through eligible enhanced alternative Prescription Drug plans (PDPs) or Medicare Advantage, Prescription Drug plans (MA-PDs), to offer a Part D benefit design that includes stable, predictable copays for select insulins (no more than $35 per prescription for the month's supply) in the deductible, initial coverage, and coverage gap phases. The Model does this by offering supplemental benefits that apply after manufacturers provide a discounted price for a broad range of insulins included in the Model. The Model does not change cost sharing in the catastrophic phase.

The Model aims to reduce Medicare expenditures while preserving or enhancing quality of care for beneficiaries. Specifically, CMS is enabling health plan innovation to offer beneficiaries lower prescription drug out-of-pocket costs by waiving a requirement that is currently a programmatic disincentive for Part D sponsors to design prescription drug plans that offer supplemental benefits to lower beneficiary cost sharing in the coverage gap phase of the Part D benefit for certain insulins.

While under the current law, outside the Model, Part D sponsors may offer supplemental benefits to lower beneficiary cost sharing through the coverage gap phase of the Part D benefit, they often chose not to do so because such benefits would reduce the amount of coverage gap discounts the pharmaceutical manufacturers would otherwise pay. Those costs, which would accrue to the plan, would then be passed on to beneficiaries in the form of higher supplemental premiums.

Because Part D sponsors compete to offer Medicare beneficiaries affordable prescription drug coverage, only a few sponsors design a benefit that has supplemental benefit coverage for brand or other applicable drugs in the coverage gap. Brand and other applicable drugs are the set of medications that often cost beneficiaries the most, and beneficiaries in the coverage gap phase pay 25 percent of the negotiated price, which may closely mirror the medication’s list price. That amount is often significantly higher than in the initial coverage phase and can represent a financial burden for Medicare beneficiaries.

Under the Model, CMS is testing a change where Part D sponsors that participate in the Model offer beneficiaries prescription drug plans that provide supplemental benefits for a broad range of insulins. Participating pharmaceutical manufacturers will pay the 70 percent discount in the coverage gap for the Part D insulins they market, but those manufacturer discount payments would now be calculated before the application of supplemental benefits under the Model.

As a result of the Model’s flexibilities for manufacturers and Part D sponsors, beneficiaries who take insulin and enroll in a plan participating in the Model should save an average of $446 in annual out-of-pocket costs on insulin, or over 66 percent, relative to their average cost-sharing today. This predictable copay will provide improved access to and affordability of insulin in order to improve medication management for beneficiaries who require insulin as part of their care.

Through the Model, CMS is also testing how participating Part D sponsors may best encourage healthy behaviors and medication adherence through Part D Rewards and Incentives programs.

CY 2023 Model Participation

CY 2023 Participating Pharmaceutical Manufacturers

On January 27, 2022, the Centers for Medicare & Medicaid Services (CMS) announced the third year of the Part D Senior Savings Model (or the “Model”), and the corresponding Request for Applications (RFA) process for participation from eligible pharmaceutical manufacturers. Completed applications, including a signed Addendum to the Medicare Coverage Gap Discount Program Agreement for Participation in the Part D Senior Savings Model, were due to CMS by February 7, 2022. Manufacturers that were approved to participate in CY 2021 or CY 2022 will continue to participate in CY 2023. The following pharmaceutical manufacturers are participating in the Model for CY 2023:

  • Eli Lilly and Company
  • MannKind Corporation
  • Mylan Specialty L.P., a Viatris Company
  • Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
  • Sanofi-Aventis U.S. LLC

Please see the list of Model drugs (PDF) for CY 2023 for more information. Please note that there is a separate list of CY 2022 Model Drugs for CY 2022. Part D Sponsor participants for CY 2022 who are looking to make formulary updates in 2022 should use the CY 2022 Model Drug List.

CY 2023 Requests for Applications for Part D Plan Sponsors

CMS released the CY 2023 Request for Applications (RFA) for Part D Plan Sponsors on February 28, 2022. The CY 2023 application process is being divided into two steps.

First, Part D sponsors must submit a complete and timely application to participate in the Part D Senior Savings Model, found at the following link: https://cms.gov1.qualtrics.com/jfe/form/SV_8oB9AvgORDf1XF4. In addition to the questions at the link provided, applicants must also submit complete and timely plan-specific information via the Excel application template (entitled, “CY 2023 Application Parent Organization”) and send by email to PartDSavingsModel@cms.hhs.gov. Links to the Excel template are provided below and in the online application. All applications and supplemental files must be submitted by April 8, 2022 at 11:59 PDT. CMS will review applications that are both complete and timely and communicate decisions on provisional approval for participation prior to June 2022.

The second and final part of the application process is for provisionally approved Part D sponsors to confirm their participation in the Model by the bid submission date of June 6, 2022, concurrent with, and as part of, their plan bid submission. In addition to the bid submission requirements, Part D Sponsors that were provisionally approved must notify CMS in writing by 11:59 PDT on June 6, 2022 of any changes from their provisionally approved application, including changes to participating PBPs.

CY 2022 Model Participation

CY 2022 Participating Pharmaceutical Manufacturers

CMS released the CY 2022 Request for Applications for Pharmaceutical Manufacturers for the Part D Senior Savings Model in January 2021. Completed applications, including a signed Addendum to the Medicare Coverage Gap Discount Program Agreement for Participation in the Part D Senior Savings Model, were due to CMS by January 27, 2021. Manufacturers that were approved to participate in CY 2021 will continue to participate in CY 2022.

The following pharmaceutical manufacturers are participating in the Model for CY 2022:

  • Eli Lilly and Company
  • MannKind Corporation
  • Mylan Specialty L.P., a Viatris Company
  • Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
  • Sanofi-Aventis U.S. LLC

Please see the list of Model drugs (PDF) for CY 2022 for more information.

CY 2022 Participating Part D Plan Sponsors

Part D sponsors had the opportunity to apply for CY 2022 participation by April 12, 2021. CMS received significant interest in the Model from Part D sponsors, and will continue to have robust participation in the Model for CY 2022. Across the nation, CMS anticipates that 2,159 prescription drug plans, including both Medicare Advantage, Prescription Drug plans (MA-PDs) and standalone Prescription Drug plans (PDPs), will participate in the Part D Senior Savings Model for CY 2022. One hundred and six (106) Part D sponsors are participating in the Model for CY 2022, covering more than 17 million total enrollees (over 3 million more enrollees than CY 2021). CMS estimates that the Model’s supplemental benefits will be directly available to more than 800,000 enrollees who use insulin and are enrolled in a participating plan for CY 2022. Seniors who use insulin in all 50 states, D.C., and Puerto Rico have a choice of a Part D Senior Savings Model participating plan in their area in CY 2022.

Beneficiaries will be able to find and compare prescription drug plans for the 2022 plan year, including plans that are participating in the Part D Senior Savings Model, through the Medicare Plan Finder on Medicare.gov during the annual open enrollment period. CMS is posting a list of Part D Senior Savings Model Plan Participants at a state and county level (see “2022 Part D Senior Savings Model Landscape File” file below).

  • 2022 Medicare Open Enrollment Information: As part of open enrollment, CMS has created a partner toolkit with information about the Part D Senior Savings Model, including how to identify and select the best Part D plan option based on a beneficiary's current prescription drugs. More information is available HERE.
  • 2022 Part D Senior Savings Model Landscape File (XLS): Use this spreadsheet to search states and counties for Part D Senior Savings Model participating plans.

The following materials are applicable for CMS-approved Part D Sponsors participating in the Part D Senior Savings Model for CY 2022. 

For questions relating to the Part D Senior Savings Model, please email PartDSavingsModel@cms.hhs.gov.

CY 2023 Materials

CY 2022 Materials

Additional Information

 

    Last updated on:
    03/17/2022