Sponsors (10)
The bill lowers and shields many young people from high insulin out-of-pocket costs and expands plan coverage requirements, but it could raise premiums, leave some insulin types less protected, and create administrative complexity for plans.
People age 26 and younger will pay no deductible and at most $35 per 30-day supply (or 25% of the negotiated price) for selected insulin, reducing their out-of-pocket spending for insulin.
Enrollees (including young adults and people with chronic conditions) will have insulin cost-sharing payments counted toward their deductibles and out-of-pocket maximums, helping them reach financial protection sooner.
Qualified health plans and catastrophic-type dependent plans must follow the rule, increasing access to affordable insulin for dependent and young adult enrollees.
Covered populations and taxpayers may face higher premiums over time because plans and issuers will need to absorb higher drug costs or restructure benefits to accommodate the mandate.
Patients who require insulin formulations or devices not among the plan-selected 'selected' insulin products could still face higher cost-sharing or lack of coverage for the alternatives they need.
Group health plans and issuers may face complex accounting and disputes because the rule requires counting manufacturer/PBM price concessions when calculating the 25% test for cost-sharing, increasing administrative burden and potential litigation or compliance costs.
Based on analysis of 2 sections of legislative text.
Requires plans to cover selected insulin for enrollees ≤26 with no deductible and cost‑sharing capped at the lesser of $35/30‑day or 25% of the negotiated price net of concessions.
Introduced April 3, 2025 by Greg Landsman · Last progress April 3, 2025
Requires group health plans and health insurance issuers to cover selected insulin products for enrollees age 26 or younger for plan years beginning on or after January 1, 2026. Plans must eliminate deductibles for those selected insulin products and cap cost‑sharing at the lesser of $35 per 30‑day supply or 25% of the negotiated price after all price concessions (including PBM concessions). The bill defines which insulin products must be covered, clarifies how those payments count toward deductibles and out‑of‑pocket maximums, and adjusts related ACA rules so certain catastrophic plans that cover dependents or young adults must provide the same access before enrollees meet standard cost‑sharing limits.