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IRA Section 11101: Part B Rebatable Drug Coinsurance Adjustment
Starting April 1, 2023, cost-sharing for Part B Rebatable Drugs must not exceed the coinsurance amount set quarterly by Medicare for that Part B Rebatable Drug. Part B Rebatable Drugs may be in either of these categories:
IRA Section 11407: Part B Insulin Cost Sharing Cap
Starting July 1, 2023, Medicare Advantage plans must cover Part B insulin at the coinsurance cap of $35 for a one-month supply of insulin. Medicare mandates that both coinsurance and copayment amounts must not exceed the $35 cap.
The Inflation Reduction Act of 2022 affects the costs of insulin and adult vaccines starting Jan. 1, 2023.
The Inflation Reduction Act (IRA) requires:
Prime / health plan will make sure that Medicare members don't pay more than $35 per month for insulin or any out-of-pocket costs for adult vaccines.
HOWEVER, until Jan. 23, 2023, it is possible that Medicare members might be charged more than $35 per month for insulin. If that is the case, Prime / the health plan will automatically generate a payment to the member for any amount they paid over $35 for insulin and will mail the member a check. They don't have to do anything to obtain the reimbursement if they were charged more than $35 per month for covered insulin. We expect any reimbursement checks to be mailed by Jan. 31, 2023.
What insulin products are included in the $35 monthly cap?
Covered insulin products are insulin products that are included on a Medicare member's health plan's formulary, treated as being included in a Medicare Part D plan's formulary as a result of a coverage determination or appeal, or covered under the transition process in accordance with § 423.120(b)(3) and obtained at a network pharmacy or an out-of-network pharmacy in accordance with § 423.124(a) and (c). These include any new insulin products that become available during the plan year. Medical supplies associated with the injection of an insulin product, when such supplies do not contain insulin and are not approved under section 505 of the FFDCA or licensed under section 351 of the PHSA, are not subject to the requirements of section 1860D-2(b)(9) of the Act.
What vaccines are covered by Part D at $0 copay?
According to the Sept. 26 memo from the Centers for Medicare & Medicaid Services (CMS), there is no cost sharing for an adult vaccine recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC). This means a covered Part D drug that is a vaccine licensed by the US Food and Drug Administration (FDA) under section 351 of the Public Health Service Act (PHSA) for use by adult populations and administered in accordance with recommendations of ACIP.
ACIP is a group of medical and public health experts that is part of the Centers for Disease Control.
Do the insulins/vaccines need to be included in the plan's formulary to be eligible for the cost reductions?
Insulins and vaccines that are included on the formulary are eligible. Any vaccine or insulin that is approved in transition or due to a formulary exception request is eligible as well.
What if a Medicare member has a coverage determination for a Non-Formulary product?
If a Medicare member requested a formulary exception for insulin or vaccine and has received an approval, those products are subject to the $35 cap (insulins) or the $0 copay (vaccines).
Beginning June 24, 2022, AllianceRx Walgreens Prime prescription home delivery service will change its name and logo to Alliance Walgreens Pharmacy.
The Centers for Medicare and Medicaid Services (CMS) announced on Apr. 4 that beneficiaries with Medicare Part B, including those enrolled in Medicare Advantage plans, now have access to FDA-approved COVID-19 tests at no cost. Medicare members may be asked to present their red, white and blue Medicare identification card to get their free OTC COVID-19 tests. Each person with Medicare Part B can get up to eight free OTC tests each month, until the end of the COVID-19 Public Health Emergency. The link above also lists participating pharmacies.
The Biden Administration recently announced that the cost of FDA-approved COVID-19 over-the-counter testing kits would be covered by private health insurers. This order excludes Medicare beneficiaries at this time, however, there are no-cost options for COVID-19 testing for our Medicare members:
Due to recent delays in the U.S. Postal Service (USPS) mail delivery, some communications from Blue Cross and Blue Shield of Illinois (BCBSIL) may not reach you as quickly as usual. This includes premium payment notices, member ID cards, explanations of benefits and other benefit materials.
We are aware of these delays and apologize for the inconvenience. To prevent any break in benefits:
During the COVID-19 pandemic, we’re lending electronic tablets to Blue Cross Medicare AdvantageSM members who meet program qualifications. Members can use the tablet to schedule telehealth visits with their doctors and to access plan benefits. For more information, call customer service at the number listed on your member ID card.
If you are losing or have lost your health care coverage during these uncertain times, we are here to help. Learn more about Medicare Special Enrollment Periods.
Last Updated: March 14, 2023
Last Updated: 09302022