CMS, Part D Capping Out-of-Pocket Insulin Spend Could Improve Adherence

The Centers for Medicare & Medicaid Services (CMS) recently launched the Senior Savings Model through Part D, which caps insulin out-of-pocket spend at no more than $35 per month for beneficiaries. Researchers of a recent JAMA Network Open research letter sought to better understand whether this cost-reducing policy had any effect on patient adherence.

“More than 3 million were taking insulin at a cost of $13.3 billion to Medicare and beneficiaries, explained Erin Trish, PhD, University of Southern California Schaeffer Center for Health Policy and Economics, Los Angeles, CA, and colleagues in the letter. “Beneficiaries’ mean out-of-pocket spending on insulin has nearly doubled over the last decade, raising concerns about access to an essential medication.”

In the study, Dr Trish and colleagues compared the use of basal insulin before and after reaching the coverage gap (where patients face increased cost-sharing) for two groups of nonsubsidized Part D enrollees: (1) beneficiaries in individual plans whose cost sharing can vary dramatically across coverage phases; and (2) those enrolled through an employer group–waiver plan where cost sharing is low and fairly constant across coverage phases.

“Among individual plan enrollees, mean cost sharing on basal insulin (per 30-day equivalent) was $50.57 ($44.40) in the initial coverage phase, $117.10 ($75.65) in the coverage gap, and $36.86 ($46.30) in catastrophic coverage,” explained the researchers.

“By contrast, mean out-of-pocket spending for employer plan enrollees was relatively low and consistent across the same three benefit phases: $32.73 ($30.21), $31.99 ($33.87), and $19.73 ($21.42), respectively.”

Beneficiaries who ended their year in the coverage gap reduced insulin usage by 5.4 percentage points compared to their usage in the initial coverage phase (62.1% vs 67.5%). Alternatively, those enrolled in employer-sponsored plans increased their insulin usage in the coverage gap (72.9% vs 70.1%).

“Capping out-of-pocket spending on insulin at $35 per month, as required by the Senior Savings Model, will substantially reduce cost-sharing for people who use insulin in the coverage gap and smooth patient liability across the year,” concluded Dr Tish and colleagues. “Our study’s findings suggest that this may improve insulin adherence for some beneficiaries.” —Edan Stanley