Medicare covers insulin pens, but your out-of-pocket cost depends on which Medicare plan you have

If you take insulin, Medicare Part B covers the insulin itself and the needles and syringes you use with pens. Part D (prescription drug coverage) covers insulin pens as durable medical equipment if your plan includes them. What you actually pay out of pocket — your copay, coinsurance, or deductible — varies by plan and by which insulin you use. Some insulins cost more than others, and your plan's formulary (the list of drugs it covers) determines whether your insulin is in a lower or higher cost tier.

The coverage rules changed in 2023: Medicare now caps your insulin copay at $35 per month for covered insulin, no matter which plan you have. This applies to insulin you get at a pharmacy with a prescription. If you use insulin that requires a pen device, you pay the $35 copay for the insulin, and the pen itself is covered separately as equipment.

Key Takeaways

  • Medicare Part B covers insulin and the supplies you use with pens (needles and syringes), while Part D covers insulin as a prescription drug through your plan's formulary.
  • Your copay for insulin is capped at $35 per month under Medicare, regardless of the insulin type or which plan you have.
  • The pen device itself is covered as durable medical equipment, but you may have a separate copay or coinsurance for the device depending on your plan.
  • Your actual out-of-pocket cost depends on your specific plan, which insulin your doctor prescribes, and whether that insulin is on your plan's formulary.
  • You should check your plan's formulary and call your pharmacy before filling a new insulin prescription to understand your exact costs.

How Medicare Part B and Part D cover insulin

Medicare Part B covers insulin as a drug, along with the needles and syringes you use to inject it. This coverage applies whether you use pens, vials, or pumps. Part D is your prescription drug plan, and it also covers insulin — but the specifics depend on which Part D plan you chose during open enrollment. Your Part D plan has a formulary, which is the official list of drugs it covers. Insulin appears on every Part D formulary, but different insulins may be in different cost tiers, meaning some cost you more than others.

When you fill an insulin prescription at a pharmacy, you are using Part D coverage, not Part B. The pharmacist will charge you based on your plan's copay structure. Part B coverage for insulin applies mainly if you get insulin through a doctor's office, clinic, or hospital outpatient setting — situations that are less common for people managing diabetes at home.

The $35 monthly copay cap and what it covers

Starting in 2023, Medicare capped your copay for insulin at $35 per month. This applies to any insulin covered by your plan, whether it is rapid-acting, long-acting, or a mix. The $35 cap is per prescription fill, not per insulin type, so if you take two different insulins, you pay $35 for each one. This is a significant change: before 2023, some people paid $50, $100, or more per month for insulin depending on their plan and the type they used.

The $35 cap applies only to insulin you get at a pharmacy with a Part D prescription. It does not explore to insulin you receive in a hospital, emergency room, or doctor's office — those settings have different payment rules. The cap also does not explore to other diabetes supplies like test strips or lancets, only to the insulin itself.

The pen device and equipment coverage

The insulin pen itself — the reusable or prefilled device that holds and delivers the insulin — is covered as durable medical equipment under Medicare Part B. This is separate from the insulin copay. You may have a copay or coinsurance for the pen device, typically 20% of the approved amount after you meet your Part B deductible. Some plans cover the pen with no additional cost, while others charge a copay of $5 to $15 per pen.

To get a pen covered, your doctor must write a prescription for it, and you must order it through a Medicare-approved durable medical equipment supplier. You cannot straightforward buy a pen at a pharmacy and expect Medicare to reimburse you — you have to go through the equipment supplier route. The supplier will verify your coverage with Medicare before sending the pen to you, so you will know your cost upfront.

How to find out what your plan covers

Your exact costs depend on your specific plan, so you need to check three things: your plan's formulary, your plan's copay structure, and whether your insulin is on the formulary. You can find your plan's formulary on Medicare.gov by logging into your account, or you can call your plan directly. The formulary lists every drug your plan covers and which tier it is in — Tier 1 drugs are usually the cheapest, and higher tiers cost more.

Before you fill a new insulin prescription, call your pharmacy and give them your plan information and the insulin name and dose. The pharmacy can tell you exactly what you will pay. If your insulin is not on your plan's formulary, your doctor can ask your plan for an exception, or you can switch to an insulin that is covered. Do not assume your current insulin is covered just because you have Medicare — plans change their formularies every year, and what was covered last year may not be this year.

What happens if your insulin is not on your plan's formulary

If your doctor prescribes an insulin that your Part D plan does not cover, you have options. First, your doctor can request a formulary exception from your plan. This is a formal request asking the plan to cover the insulin anyway, usually because you have already tried other insulins on the formulary and they did not work for you. The plan has 72 hours to respond to an urgent request and 14 days to respond to a standard request.

If the exception is denied, you can ask your doctor to prescribe a different insulin that is on your plan's formulary. Many insulins work similarly, and your doctor can often switch you without difficulty. You can also contact your plan's customer service line and ask which insulins are in the lowest cost tier — this helps you and your doctor make a choice that fits your budget. If you disagree with your plan's decision, you have the right to file an appeal, and your plan must tell you how to do this.

Costs at different stages of the year

Your insulin costs may change depending on where you are in the calendar year. In January, you start with a deductible — the amount you have to pay out of pocket before your plan starts paying. Once you meet your deductible, you pay your copay (capped at $35 for insulin). As you spend more on prescriptions throughout the year, you may enter the coverage gap, sometimes called the "donut hole," where you pay a higher percentage of drug costs. After you spend enough to exit the coverage gap, your plan pays a larger share again.

The exact amounts and thresholds change each year. For 2024, the Part D deductible can be up to $545, and the coverage gap begins after you and your plan have spent $5,850 together on covered drugs. These numbers increase slightly each year. Your plan's materials should explain these stages, or you can call your plan to ask where you are in the year and what your costs will be for the rest of the year.

Frequently Asked Questions

Do I have to use a specific brand of insulin pen?

Your plan's formulary may cover some insulin brands but not others. Your doctor can prescribe any insulin, but your plan will only pay for the ones on its formulary. If your doctor prescribes an insulin your plan does not cover, ask your doctor to prescribe one that is covered, or request a formulary exception from your plan.

What if I cannot afford the $35 copay?

If you have limited income, you may be able to get help through the Extra Help program (also called Low-Income Subsidy), which reduces your Part D copays and deductibles. You can also ask your insulin manufacturer if they offer patient information programs that help cover costs. Contact your local Area Agency on Aging or call 211 to find local resources.

Does Medicare cover insulin pumps?

Yes, Medicare Part B covers insulin pumps as durable medical equipment if your doctor prescribes one and you meet certain criteria. You will need a prescription and must order through a Medicare-approved supplier. Your copay is typically 20% of the approved amount after you meet your Part B deductible, not the $35 insulin copay.

What if I switch Medicare plans during open enrollment?

Your new plan's formulary may be different from your old plan's, so your insulin coverage could change. Before you switch plans, check whether your current insulin is on the new plan's formulary and what your copay will be. Open enrollment runs from October 15 to December 7 each year, and changes take effect January 1.

Can I use GoodRx or a discount card instead of Medicare?

You can use a discount card or GoodRx, but you cannot use both Medicare and a discount card at the same time — you have to choose one. For most people with Medicare, the $35 insulin copay through your plan is cheaper than a discount card price. Compare the prices before you fill your prescription to see which option costs less.