This bill addresses the rising cost of insulin, which has been a major financial burden for many people with diabetes. If passed, it would provide financial relief by limiting how much individuals pay out-of-pocket for insulin each month, making this life-saving medication more accessible and predictable in cost.
Without this bill, many individuals could continue to face high deductibles and uncapped costs for insulin, potentially leading them to ration their medication or forgo it entirely due to expense, which can have severe health consequences. It aims to reduce the stress and financial strain associated with managing a chronic condition.
KEY PROVISIONS
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PROVISION 01
Caps out-of-pocket cost for a 30-day supply of selected insulin products at the lesser of $35 or 25% of the negotiated price.
This directly limits the monthly financial burden for insulin users with private insurance.
PROVISION 02
Prohibits health plans and insurers from applying a deductible to selected insulin products.
This ensures individuals do not have to pay a large sum upfront before the cost cap applies.
PROVISION 03
Specifies that payments made under the cost-sharing cap must count towards any deductible or out-of-pocket maximum under the plan.
This ensures the capped payments contribute to reaching annual limits on healthcare spending, protecting consumers from excessive overall costs.
PROVISION 04
Defines "selected insulin products" as at least one of each dosage form and type, chosen by the plan or insurer, and clarifies that plans are not required to cover or cap costs for out-of-network or non-selected insulin.
This gives flexibility to insurers in product selection but ensures a basic level of capped options while allowing higher costs for out-of-network or non-preferred options.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
This bill addresses the rising cost of insulin, which has been a major financial burden for many people with diabetes. If passed, it would provide financial relief by limiting how much individuals pay out-of-pocket for insulin each month, making this life-saving medication more accessible and predictable in cost.
Without this bill, many individuals could continue to face high deductibles and uncapped costs for insulin, potentially leading them to ration their medication or forgo it entirely due to expense, which can have severe health consequences. It aims to reduce the stress and financial strain associated with managing a chronic condition.
KEY PROVISIONS
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high
Caps out-of-pocket cost for a 30-day supply of selected insulin products at the lesser of $35 or 25% of the negotiated price.
This directly limits the monthly financial burden for insulin users with private insurance.
high
Prohibits health plans and insurers from applying a deductible to selected insulin products.
This ensures individuals do not have to pay a large sum upfront before the cost cap applies.
med
Specifies that payments made under the cost-sharing cap must count towards any deductible or out-of-pocket maximum under the plan.
This ensures the capped payments contribute to reaching annual limits on healthcare spending, protecting consumers from excessive overall costs.
med
Defines "selected insulin products" as at least one of each dosage form and type, chosen by the plan or insurer, and clarifies that plans are not required to cover or cap costs for out-of-network or non-selected insulin.
This gives flexibility to insurers in product selection but ensures a basic level of capped options while allowing higher costs for out-of-network or non-preferred options.
For plan years beginning on or after January 1, 2026
Requirements with respect to cost-sharing for certain insulin products become effective for group health plans and health insurance issuers.
GLOSSARY
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Cost-sharing
The portion of healthcare expenses that a person covered by an insurance plan must pay out of their own pocket, such as copayments, deductibles, or coinsurance.
Deductible
The amount of money a person must pay for healthcare services before their insurance plan starts to pay.
Group Health Plan
An employee welfare benefit plan that provides medical care to employees and their families, typically offered by an employer or employee organization.
Health Insurance Issuer
A health insurance company or organization that offers health insurance policies.
Negotiated Price
The discounted price for a medication or service that an insurance plan or its pharmacy benefit manager has agreed upon with a pharmacy or manufacturer.
Plan Year
The 12-month period during which an insurance plan provides coverage; it may not always align with the calendar year.
Public Health Service Act
A federal law that authorizes a wide range of public health programs and activities, including those related to health insurance.
ACTION TIMELINE
2 EVENTS
NOV 21, 25
Introduced in House
INTROREFERRAL
NOV 21, 25
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
A federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans.