How much will people with diabetes in Pa. and N.J. save with the new Medicare insulin cap?
Medicare's new $35 monthly cap on insulin costs could save people in Pa and NJ hundreds of dollars a year.
Insulin will cost no more than $35 a month for people with prescription-drug coverage through Medicare, a rule change that is expected to save people with diabetes hundreds of dollars a year.
The rule, effective Jan. 1, applies to people who have traditional Medicare with a Part D drug plan, as well as people with a Medicare Advantage plan that includes prescription drugs. The cap takes effect in July for the minority of insulins covered under Medicare Part B.
The Department of Health and Human Services estimates the change will save insulin users an average of $500 a year, based on 2020 medication costs.
In Pennsylvania, nearly 80,200 people stand to save an average of $543 a year. And in New Jersey, about 39,600 insulin users with Medicare could save an average of $511 a year, according to HHS estimates.
Prior to the rule, insulin users with Medicare spent an average of $54 per month, according to an analysis by the Kaiser Family Foundation, a price that was unaffordable to many and led some to ration their supply at the risk of dangerous complications.
“No one should have to skip or ration their insulin because they can’t afford it,” HHS Secretary Xavier Becerra said during a call with reporters Tuesday.
» READ MORE: How Medicare drug costs could change under the Inflation Reduction Act
The insulin price cap is one of several measures in the Inflation Reduction Act intended to stem high and rising prescription-drug costs. The legislation also allowed Medicare to begin negotiating prices for a small number of high-use medications and capped the total amount people with Medicare can pay for prescription drugs.
Insulin, in particular, has been a focus among critics of drug prices. The Centers for Disease Control and Prevention considers diabetes one of the costliest chronic health conditions, both because of insulin’s price and the expensive complications patients experience when they can’t afford the medication needed to properly manage their disease.
About 17% of people with diabetes reported rationing their medication or even skipping doses in 2019, according to a 2022 HHS report on insulin affordability.
People with diabetes, a condition in which the body doesn’t produce its own insulin or doesn’t regulate it properly, rely on insulin produced by pharmaceutical companies to regulate their blood sugar. For people with type 1 diabetes, which occurs when the body does not produce any insulin of its own, going without medication can lead to diabetic ketoacidosis, a life-threatening emergency in which the body begins to shut down. Other long-term complications of poorly managed blood sugar include damage to vital organs and vision.
» READ MORE: The new faces of Type 1 diabetes
The new price cap takes aim at a major cost driver for people with diabetes. In 2019, insulin accounted for 20% of all diabetes care costs — some $41 billion out of a total $202 billion, according to the 2022 HHS affordability report.
Other Medicare cost control measures in the Inflation Reduction Act may offer some relief to people with other chronic conditions that are expensive to manage:
Beginning in 2025, out-of-pocket spending for prescription drugs will be capped at $2,000 for people with Medicare Part D.
In 2026, Medicare will be able to negotiate prices for top-selling medications.
The Philadelphia Inquirer is one of more than 20 news organizations producing Broke in Philly, a collaborative reporting project on solutions to poverty and the city’s push toward economic justice. See all of our reporting at brokeinphilly.org.