Sponsors (8)
The bill makes insulin far more affordable for people 26 and under and standardizes coverage rules, at the cost of higher plan/employer expenses, administrative complexity, and some potential confusion in plan value comparisons.
People age 26 and younger with diabetes will pay no deductible and at most $35 per 30‑day insulin supply (or 25% of negotiated price), and those cost‑sharing payments count toward deductibles and out‑of‑pocket maximums, cutting monthly out‑of‑pocket costs and lowering total annual drug spending for affected individuals and families.
Coverage rules are standardized across ERISA, the Public Health Service Act, and the tax code, reducing plan variation and increasing predictability for families, employers, and plan sponsors.
Health plans and employers will face higher drug coverage costs to absorb the insulin cost cap, which could lead to higher premiums, increased employer contributions, or shifted costs for taxpayers and families over time.
Tying a $35 cap to negotiated price concessions may change rebate/negotiation practices and create administrative complexity for plans and regulators, increasing compliance burdens and potentially altering market incentives.
Excluding the deductible exemption from actuarial value calculations could affect plan metal‑level designations and make consumer comparisons under the ACA less straightforward, potentially confusing enrollees shopping for coverage.
Based on analysis of 2 sections of legislative text.
Introduced April 3, 2025 by Greg Landsman · Last progress April 3, 2025
Requires group health plans and health insurance issuers to cover specified insulin products for enrollees age 26 or younger without applying a deductible and with cost-sharing limited per 30‑day supply to the lesser of $35 or 25% of the negotiated price (after concessions). The rule applies to ERISA plans, group market plans, and relevant tax code provisions and takes effect for plan years beginning on or after January 1, 2026. Also clarifies that these low out‑of‑pocket payments must count toward a plan’s deductible and out‑of‑pocket maximum, changes how actuarial value treats the deductible exemption for these insulin products, requires catastrophic plans to provide the coverage before an enrollee reaches the plan’s annual limit, and lets HHS, Labor, and Treasury issue guidance to implement the rule. Definitions require inclusion of at least one dosage form of each insulin type when available and treat licensed biologic and biosimilar insulins as covered products.