Sponsors (12)
The bill lowers and stabilizes out‑of‑pocket costs for many people with diabetes and improves immediate access to selected insulin products, but may leave gaps for those needing non‑covered formulations, raise costs for out‑of‑network users, and shift costs or administrative complexity onto plans, employers, and the health‑care system.
People with diabetes (especially low‑income and chronically ill patients) will pay much less out‑of‑pocket for covered in‑network insulin because cost‑sharing is capped at $35 per 30‑day supply or 25% of the negotiated price beginning in 2026.
Insured patients (particularly those with diabetes) will get immediate access to selected covered insulin products without having to meet a deductible, reducing delays in obtaining essential medication.
Cost‑sharing payments for insulin will count toward plan deductibles and out‑of‑pocket maximums, helping patients reach coverage thresholds sooner and reducing total annual drug spending for frequent users.
Patients with diabetes who need specific insulin brands or formulations may not benefit if plans limit the policy to a plan‑selected list of "selected insulin products," risking therapy disruption or additional costs for excluded products.
People who rely on out‑of‑network pharmacies or providers could face higher cost‑sharing and access barriers for insulin, leaving some patients exposed to substantial extra costs.
Insurers and employers may incur higher plan costs that could be passed on to taxpayers, employees, and middle‑class families through higher premiums, reduced benefits, or other tradeoffs.
Based on analysis of 2 sections of legislative text.
Caps in‑network insulin cost‑sharing to no deductible and max $35 or 25% of negotiated net price per 30‑day supply for selected insulin products starting in 2026.
Requires group health plans and individual/group health insurance policies to cover selected insulin products without applying any deductible and to limit in‑network cost‑sharing for a 30‑day supply to the lesser of $35 or 25% of the negotiated price net of all price concessions, beginning for plan years starting on or after January 1, 2026. Plans may designate at least one dosage form of each insulin type as a “selected insulin product”; out‑of‑network insulin may be excluded or subject to higher cost‑sharing. The law counts any cost‑sharing paid under this rule toward a plan’s deductible and out‑of‑pocket maximum, clarifies that insurers are not required to cover non‑selected insulin products under these cost limits, and treats price concessions (including those to PBMs and other third parties) as part of the negotiated price used to calculate the cap.
Official title: To amend title XXVII of the Public Health Service Act, the Internal Revenue Code of 1986, and the Employee Retirement Income Security Act of 1974 to establish requirements with respect to cost-sharing for certain insulin products, and for other purposes.
Introduced November 21, 2025 by Angela Craig · Last progress November 21, 2025