Part D Senior Savings Model

The Inflation Reduction Act will cap cost-sharing for each insulin product covered under a Medicare prescription drug plan at $35 for a month’s supply beginning in January 2023. Also, Part D deductibles will not apply to these covered insulin products. The Part D Senior Savings Model, which first tested a similar benefit in Model-participating plans, will continue in 2023.

Note for people with Medicare: Visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) if you have questions or need help understanding your options. 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 enhanced alternative Part D plan options that offer lower out-of-pocket costs for insulin as supplemental benefits. This voluntary Model began on January 1, 2021. 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”) was 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. 

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.

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

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 Participating Part D Plan Sponsors

Part D sponsors had the opportunity to apply for CY 2023 participation by April 8, 2022. CMS anticipates that over 2,500 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 2023, which begins on January 1, 2023.

The following materials are applicable for CMS-approved Part D Sponsors participating in the Part D Senior Savings Model for CY 2023.

CY 2022 Model Participation

CY 2022 Participating Pharmaceutical Manufacturers

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

Across the nation, 2,159 prescription drug plans, including both Medicare Advantage, Prescription Drug plans (MA-PDs) and standalone Prescription Drug plans (PDPs), are participating 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 are 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.

 CMS has posted a CY 2022 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

Evaluation Reports

Latest Evaluation Report

Two Pager: At-A-Glance Report (PDF)

 

    Last updated on:
    11/16/2022