CMS Part D Senior Savings Model

In 2019, more than 90% of Medicare Part D members were enrolled in a plan that offered the Defined Standard coinsurance for Insulin products in the coverage gap (25%), meaning that a non-low income (non-LIS) beneficiary would pay $125 for a $500 Insulin drug in this benefit phase.

On March 11, 2020, CMS announced the release of the Part D Senior Savings Model for CY2021. This is a voluntary opt-in model, which reduces financial disincentives for plans to offer enhanced gap coverage for brand Insulin drugs, while also capping Insulin cost sharing at a $35 copay for non-LIS beneficiaries for a 30-days supply through all phases of the benefit, except for the catastrophic phase. CMS estimates that approximately 1.3 million non-LIS beneficiaries enrolled in individual Medicare Advantage (MAPD) and Part D Prescription Drug Plans (PDP) are Insulin-dependent, and most of those beneficiaries are already enrolled in an Enhanced Alternative plan. In this paper, we have outlined a number of considerations for Part D plans as they contemplate how this demonstration might impact their market and whether they should participate.