EPI Act

To establish a cap on out-of-pocket costs for insulin. 1. Short title This Act may be cited as the Ending Pricey Insulin Act EPI Act 2. Capping out-of-pockets cost of insulin (a) Individuals enrolled in certain health plans Title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg 2729A. Coverage of insulin drugs Beginning with plan year 2022, a group health plan or health insurance issuer offering group or individual health insurance coverage that provides coverage for prescription insulin drugs may not impose any deductible, copayment, coinsurance, or other cost-sharing requirement with respect to such drugs that results in out-of-pocket costs to the enrollee that exceed $50 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the enrollee's insulin prescriptions. . (b) Individuals enrolled in other coverage (1) Medicare, Medicaid, and CHIP The Secretary of Health and Human Services shall take such administrative action as is necessary to ensure that in no event shall any State plan or waiver under title XIX or XXI of the Social Security Act or prescription drug plan under part D of title XVIII of such Act or MA–PD plan under part C of such title of such Act that provides coverage for prescription insulin drugs impose any deductible, copayment, coinsurance, or other cost-sharing requirement with respect to such drugs that results in out-of-pocket costs to an individual enrolled in such coverage that exceeds $50 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the enrollee's insulin prescriptions. (2) Veterans The Secretary of Veterans Affairs shall take such administrative action as is necessary to ensure that prescription insulin drugs written by eligible health care providers for veterans do not impose any deductible, copayment, coinsurance, or other cost-sharing requirement with respect to such drugs that results in out-of-pocket costs to the veteran that exceeds $50 per prescription for a 30-day supply of covered prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the veteran's insulin prescriptions. For purposes of the preceding sentence, the term eligible health care provider (3) TRICARE The Secretary of Defense shall take such administrative action as is necessary to ensure that prescription insulin drugs written by health care providers for enrollees in the TRICARE program under chapter 55 3. Cap on cash price for insulin for individuals without health insurance Beginning on January 1, 2022, in the case of an individual who is not enrolled in any public or private health plan, the cash price for a 30-day supply of such individual's prescription insulin drugs, regardless of the amount of insulin drugs needed to fill the individual's insulin prescriptions, shall be not more than $50. 4. Retroactive effect In the event that this Act is enacted after January 1, 2022— (1) any out-of-pocket cost to an enrollee for insulin in plan year 2022 or a subsequent plan year that is in excess of the amount specified in section 2729A of the Public Health Service Act (as added by section 2) shall be reimbursed by the group health plan or health insurance issuer to the enrollee; (2) any amount paid by an uninsured individual for insulin on or after January 1, 2022, that is in excess of the amount specified in section 3 shall be reimbursed by the insulin manufacturer to the individual; and (3) any amount paid by an enrollee or veteran for insulin on or after January 1, 2022, that is in excess of the amount specified in paragraph (1) (2), or (3), as applicable, of section 2(b) shall be reimbursed by the Secretary of Health and Human Services, the Secretary of Veterans Affairs, or the Secretary of Defense, as applicable, to the enrollee or veteran.

Summary: Ending Pricey Insulin Act or the EPI Act This bill establishes a maximum out-of-pocket cost of $50 for a 30-day supply of insulin. Specifically, no private or public health insurance plan may charge an enrollee more than $50 for a 30-day supply of insulin, regardless of the amount of insulin prescribed for that period. This includes any deductible, co-payment, coinsurance, or other cost-sharing requirement. This $50 limit also applies to the cash price for insulin prescriptions for uninsured individuals. The requirements of this bill apply beginning on January 1, 2022, irrespective of the date this bill is enacted.