Sponsors (9)
The bill makes insulin significantly more affordable and predictable for people 26 and under and standardizes minimum coverage, at the cost of higher insurer/employer drug spending that could raise premiums and incentives for plans to limit covered products, plus added administrative complexity.
People aged 26 and under who use insulin will pay no deductible and face capped copays (no more than $35 or 25% per 30-day supply), and those payments will count toward plan deductibles and out-of-pocket maximums, immediately lowering out-of-pocket spending and accelerating access to cost protections.
Enrollees age 26 and under on catastrophic plans will gain earlier access to selected insulin products (covered before the plan-year out-of-pocket limit), improving access for high-need individuals on those plans.
All affected plans must meet clearer definitions and cover at least one insulin dosage form/type, reducing plan-to-plan variation and helping ensure basic product availability across plans.
Health insurers and employers will face higher drug spending from the coverage/cost-sharing limits, which could be passed on over time as higher premiums or altered employer contributions affecting taxpayers, middle-class families, and small-business owners.
Because the 25% cap is calculated from the negotiated price net of concessions, enrollees may still face high copays if negotiated prices are high, limiting savings for some insulin users.
Plans may restrict coverage to the insurer-selected insulin products (one per type/dosage form), potentially leaving some branded or newer insulins uncovered and harming patients who need specific formulations.
Based on analysis of 2 sections of legislative text.
Requires insurers and group plans to cover selected insulin for enrollees age 26 or younger with no deductible and cost-sharing capped at the lesser of $35 or 25% of the negotiated net price.
Introduced April 3, 2025 by Greg Landsman · Last progress April 3, 2025
Requires group and individual health plans to cover certain insulin products for enrollees age 26 and younger without a deductible and with cost-sharing capped per 30-day supply at the lesser of $35 or 25% of the plan’s negotiated price after all price concessions. The rule takes effect for plan years beginning on or after January 1, 2026, and requires those cost-sharing payments to count toward plan deductibles and out-of-pocket maximums, while preserving certain actuarial and regulatory calculations and allowing plans to apply other permitted cost-sharing for insulin not covered by the new rule.