HR6255-119

What This Bill Does

The Affordable Insulin Now Act requires group health plans and health insurance issuers offering group or individual coverage, for plan years beginning on or after January 1, 2026, to cover selected insulin products without a deductible and with cost-sharing capped at the lesser of $35 per 30-day supply or 25 percent of the negotiated price net of price concessions, including concessions received by pharmacy benefit managers or other third-party service providers. Selected insulin products must include at least one dosage form of each different type of marketed insulin when available, such as vial, pump, inhaler, rapid-acting, short-acting, intermediate-acting, long-acting, ultra-long-acting, and premixed products. Cost-sharing counts toward deductibles and out-of-pocket maximums, but plans need not cover selected insulin from out-of-network providers and may impose different cost-sharing on nonselected insulin products when otherwise lawful. The bill applies parallel requirements through the Public Health Service Act, Internal Revenue Code, and ERISA.

Who Benefits and How

People with diabetes using selected insulin products benefit from no deductible and a predictable per-30-day cost-sharing cap. Families and workers in group or individual coverage benefit when insulin spending counts toward deductibles and out-of-pocket maximums. Employers and plans may benefit from clearer Federal rules on selected insulin products across PHS Act, tax-code, and ERISA regimes.

Who Bears the Burden and How

Health insurance issuers, group health plans, employer plan sponsors, and pharmacy benefit managers must redesign formularies, cost-sharing, deductible accounting, and concession calculations by 2026. Plans and issuers may bear higher claim costs or premium pressure from lower patient cost-sharing. Federal agencies enforcing PHS Act, Internal Revenue Code, and ERISA requirements must issue guidance and monitor compliance.

Key Provisions

• Requires group and individual health coverage to cover selected insulin products beginning with plan years on or after January 1, 2026.
• Caps selected insulin cost-sharing at the lesser of $35 per 30-day supply or 25 percent of net negotiated price.
• Bars deductibles for selected insulin products and counts insulin cost-sharing toward deductibles and out-of-pocket maximums.
• Defines selected insulin to include at least one dosage form of each different type of marketed insulin when available.
• Preserves network limits and allows different cost-sharing for nonselected insulin products when otherwise lawful.