December 22, 2022
Starting Jan. 1, 2023, the Inflation Reduction Act (IRA) of 2022 will affect the costs of insulin and adult vaccines for Medicare members. The act requires:
- The cost of a covered insulin to be capped at $35 for a month’s supply for those enrolled in a Medicare prescription drug plan.
- No out-of-pocket costs for adult vaccines covered under Medicare Part D.
In January 2023, some Medicare members may be charged more than $35 per month for a covered insulin. If that happens, we will reimburse members for any amount paid over $35. Reimbursement checks would be mailed by Jan. 31, 2023.
Here are some frequently asked questions about the changes:
What insulin products are included in the $35 per month cap?
Included in the cap are insulin products covered under Medicare prescription drug plans and dispensed at a network retail or mail order pharmacy, according to the Centers for Medicare & Medicaid Services.
What vaccines are covered by Medicare Part D at a $0 copay?
There is no cost sharing for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC). This includes the shingles and Tetanus-Diphtheria-Whooping Cough vaccines. ACIP is a group of medical and public health experts that is part of the CDC.
Do the insulins or 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 coverage exception request is also eligible.
What if a Medicare member has a coverage determination for a non-formulary product?
If a Medicare member has 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).
For more information, you can read the CMS fact sheet.
The information provided here is only intended to be a summary of the law that has been enacted and is not intended to be an exhaustive description of the law or a legal opinion of such law. If you have any questions regarding the law mentioned here, you should consult with your legal advisor.
The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.