Medicare Diabetes Coverage: The $35 Insulin Cap, CGMs, and Supplies

Here's the short version. Under Medicare, a one-month supply of each covered insulin product costs you no more than $35, and no deductible applies to insulin. The cap works under both Part B and Part D. If you have diabetes, Medicare may also cover a continuous glucose monitor (CGM) when your doctor orders it and you take insulin or have a history of low blood sugar problems. Blood sugar monitors and test strips are covered by Part B as durable medical equipment. You pay 20% of the Medicare-approved amount after the Part B deductible. The details below tell you which part of Medicare pays for what.

The $35 insulin cap

The cost of a one-month supply of each Part B-covered or Part D-covered insulin product can't be more than $35. You don't have to pay a deductible for insulin. If you get a three-month supply, your cost can't be more than $35 for each month's supply of each covered insulin. That generally means no more than $105 for three months.

• Under Part D, the $35 limit applies to everyone who takes insulin, even people who get Extra Help.
• If you have Part B and a Medigap policy that pays your Part B coinsurance, your Medigap policy should cover the cost ($35 or less) of your Part B insulin.
• The cap is per covered insulin product. Your Part D plan's formulary decides which insulins it covers. If your insulin isn't on the list, see how to ask for a formulary exception.

Which part of Medicare pays for your insulin

This is the part that confuses people. It depends on how you take your insulin.

• Part B covers insulin if you use an insulin pump that is covered under Part B's durable medical equipment (DME) benefit.
• Part B does not cover insulin you inject yourself with pens or syringes, disposable "patch" pumps or the insulin used with them, or supplies like syringes, needles, alcohol swabs, and gauze.
• Part D may cover injectable insulin (pens or needles), insulin for pumps that aren't covered as DME (like patch pumps changed every 2 to 3 days), inhaled insulin, and certain supplies used for injections.

Two things follow from this. If you inject insulin and don't have Part D, you'll pay all of the cost of your syringes and other injection supplies under Part B. And in some parts of the country, you may have to use specific pump suppliers for Medicare to cover a durable insulin pump. Our Part D guide explains formularies and plan choice.

Continuous glucose monitors (CGMs)

A CGM tracks your glucose through a device attached to your body. Medicare may cover a CGM and related supplies, like sensors, if your doctor or other provider orders them and you meet these conditions:

• You take insulin, or you have a history of problems with low blood sugar (hypoglycemia).
• You or your caregiver have had enough training to use the CGM as directed.

Your provider must evaluate you and confirm you're eligible before ordering the device. CGMs are covered by Part B as DME. After you meet the Part B deductible, you pay 20% of the Medicare-approved amount if your supplier accepts assignment.

Make sure your doctor and your DME supplier are enrolled in Medicare, and ask the supplier whether it accepts assignment before you get the device. A supplier that doesn't accept assignment can charge you more. For rented equipment, confirm the supplier will accept assignment for every rental month. Otherwise you may have to pay the full cost up front and wait for Medicare to pay you back.

Blood sugar monitors, test strips, and other supplies

Part B covers blood glucose monitors that your doctor prescribes for home use, along with test strips and some other diabetic testing supplies. These count as DME. After the Part B deductible, you pay 20% of the Medicare-approved amount when the supplier accepts assignment.

Medicare pays for different kinds of DME in different ways. You may need to rent an item, buy it, or choose between the two. Some items become yours after a set number of rental payments. Suppliers that participate in Medicare must accept assignment, which means they can only charge you the coinsurance and deductible on the approved amount.

Screenings, training, and exams Medicare covers

• Diabetes screenings. Part B covers blood tests to check for diabetes if your provider decides you're at risk. You pay nothing if your provider accepts assignment, and you can get up to 2 screenings a year. Risk factors include high blood pressure, a history of abnormal cholesterol, obesity, or a history of high blood sugar.
• Diabetes self-management training. Part B covers outpatient training in eating well, staying active, checking your blood sugar, and taking your drugs. You need an order from your provider. You pay 20% of the approved amount after the deductible.
• Eye exams. Part B covers an exam for diabetic retinopathy once a year from an eye doctor licensed in your state. You pay 20% after the deductible, plus a copayment in a hospital outpatient setting.
• Foot care. Part B covers foot exams or treatment every 6 months if you have diabetes-related nerve damage in your lower legs with loss of protective sensation. You pay 20% after the deductible.

Medicare Advantage, Extra Help, and diabetes

A Medicare Advantage plan must cover all medically necessary services that Original Medicare covers, though your copays and supplier rules are set by the plan. Most of these plans include Part D drug coverage, so the insulin cap applies there too. Check the plan's formulary for your insulin and its DME rules for your CGM before you enroll.

If your income and resources are limited, Extra Help lowers your Part D premium, deductible, and copays. People with full Medicaid, a Medicare Savings Program, or SSI get it automatically. See Getting Help Paying to check whether you qualify.

Common questions

Related pages

• Medicare Part D — formularies, tiers, and coverage phases.
• Medicare Part B — medical insurance, DME, and preventive care.
• Understanding Your Costs — deductibles, copayments, and coinsurance.
• Part D Formulary Exceptions and Appeals — when your plan won't cover a drug.
• Medicare Prescription Payment Plan — spreading drug costs into monthly payments.

Official sources: Medicare.gov: Insulin, Medicare.gov: Continuous glucose monitors, and Medicare.gov: Blood sugar test strips.