Medicare Part D Overcharged: Insulin, Vaccine, or OOP Cap

What This Means

The Inflation Reduction Act changed the law so that Medicare Part D plans cannot charge you more than certain amounts for specific drugs and vaccines. These are not discounts or benefits your plan chose to offer. They are federal law. If you paid more than these amounts, the pharmacy or your plan made an error, and you are owed money back.

There are three price caps you should know about. First, insulin is capped at $35 per month. No matter which insulin product you use — pens, vials, or biosimilars — your Part D plan cannot charge you more than $35 for a one-month supply. This applies to all Medicare Part D plans, including Medicare Advantage plans with drug coverage. Second, adult vaccines recommended by the CDC are free. You should pay $0 out of pocket for vaccines like shingles (Shingrix), Tdap, hepatitis B, and RSV vaccines when you get them through your Part D plan. Third, your total out-of-pocket drug costs are capped at $2,000 per year. Once you have paid $2,000 in a calendar year for Part D covered drugs, your plan must pay 100% of your covered drug costs for the rest of the year.

If you looked at a pharmacy receipt and the numbers don’t match these caps, you were overcharged. This page will walk you through exactly what to do to get your money back.

Why This Happens

• The pharmacy’s computer system hasn’t been updated. Pharmacy billing systems need to receive updated pricing information from your Part D plan. If the system wasn’t updated to reflect the IRA caps, it may charge you the old, higher amount.
• Your Part D plan didn’t communicate the cap to the pharmacy. Your plan is responsible for telling the pharmacy’s system that the cap applies to your prescription. If the plan failed to send this information, the pharmacy charges you the wrong amount.
• You haven’t been identified as IRA-eligible in your plan’s system. Your plan’s records may not correctly flag you as a Medicare Part D enrollee who qualifies for IRA protections. This can happen after plan changes, late enrollment, or data entry errors.
• The pharmacy applied the wrong quantity or days’ supply. The $35 insulin cap is per monthly supply. If the pharmacy processed your prescription as a 90-day supply but only applied a one-month cap, or billed the wrong quantity, your copay may come out too high.
• You already hit the $2,000 cap but the system didn’t catch up. There can be a delay between when your spending reaches $2,000 and when the plan’s system reflects that. In the meantime, you may be charged for drugs that should now be free.

Should You Appeal?

What To Do Next

1. Gather your pharmacy receipts. Find every receipt that shows what you paid. You need the date, the drug name, the amount charged, and the pharmacy name. If you don’t have paper receipts, your pharmacy can print copies, or you can check your Part D plan’s online portal for claims history.
2. Call your Part D plan’s member services number. This number is on the back of your plan’s member ID card. Tell them you were overcharged under the Inflation Reduction Act price caps. Be specific: say whether it was insulin (over $35), a vaccine (should be $0), or charges after you hit the $2,000 annual cap. Ask for a refund of the difference between what you paid and what the law allows.
3. If the plan doesn’t resolve it, call 1-800-MEDICARE (1-800-633-4227). Tell the representative that your Part D plan is not honoring the Inflation Reduction Act price caps. Medicare can intervene directly with your plan. TTY users can call 1-877-486-2048.
4. File a complaint with Medicare if needed. If your plan does not issue a refund within 30 days, you can file a formal complaint (called a grievance) with your plan, or file a complaint directly with Medicare at medicare.gov/complaints. This creates an official record and puts pressure on the plan to act.
5. Ask about the Medicare Prescription Payment Plan. If your drug costs are high early in the year, ask your plan to enroll you in the Medicare Prescription Payment Plan. This lets you spread your annual out-of-pocket costs into smaller monthly payments instead of paying large amounts at the pharmacy counter. All Part D plans must offer this option.
6. Contact your SHIP for free help. Your State Health Insurance Assistance Program provides free, unbiased counseling to people with Medicare. A SHIP counselor can help you request a refund, file a complaint, or review your drug costs. Find your local SHIP at shiphelp.org or call 1-800-MEDICARE.

Sources

• CMS: Inflation Reduction Act and Medicare
• Medicare.gov: Part D Costs — Lower Costs for Prescription Drugs
• CMS: Medicare Prescription Payment Plan
• Medicare.gov: Filing a Complaint About Your Medicare Plan
• HHS: Inflation Reduction Act Lowers Health Care Costs for Millions of Americans

Frequently Asked Questions