Cap Insulin Prices Act

To reduce the price of insulin for patients. 1. Short title This Act may be cited as the Cap Insulin Prices Act 2. Reduction in cost-sharing for covered insulin products under Medicare part D Section 1860D–2(b)(9)(D) of the Social Security Act ( 42 U.S.C. 1395w–102(b)(9)(D) (1) by redesignating clause (ii) as clause (iii); (2) in clause (i)— (A) by striking plan years 2023, 2024, and 2025 plan year 2023 (B) by striking and (3) by inserting after clause (i) the following new clause: (ii) during plan years 2024 and 2025, $25; and ; and (4) in clause (iii)(I), as redesignated by paragraph (1) of this section, by striking $35 $25 3. Requirements with respect to cost-sharing for insulin products (a) In general Part D of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–111 et seq. 2799A–11. Requirements with respect to cost-sharing for certain insulin products (a) In general For plan years beginning on or after January 1, 2024, a group health plan or health insurance issuer offering group or individual health insurance coverage shall provide coverage of selected insulin products, and with respect to such products, shall not— (1) apply any deductible; (2) impose any cost-sharing requirement in excess of the lesser of, per 30-day supply— (A) $25; or (B) the amount equal to 25 percent of the negotiated price of the selected insulin product net of all price concessions received by or on behalf of the plan or coverage, including price concessions received by or on behalf of third-party entities providing services to the plan or coverage, such as pharmacy benefit management services; or (3) impose any utilization management practices such as prior authorization, step therapy protocols, or other similar conditions on such products, except as clinically justified and as specified by the Secretary. (b) Definitions In this section: (1) Selected insulin products The term selected insulin products (2) Insulin defined The term insulin (c) Out-of-Network providers Nothing in this section requires a plan or issuer that has a network of providers to provide benefits for selected insulin products described in this section that are delivered by an out-of-network provider, or precludes a plan or issuer that has a network of providers from imposing higher cost-sharing than the levels specified in subsection (a) for selected insulin products described in this section that are delivered by an out-of-network provider. (d) Rule of construction Subsection (a) shall not be construed to require coverage of, or prevent a group health plan or health insurance coverage from imposing cost-sharing other than the levels specified in subsection (a) on, insulin products that are not selected insulin products, to the extent that such coverage is not otherwise required and such cost-sharing is otherwise permitted under Federal and applicable State law. (e) Application of cost-Sharing towards deductibles and out-of-Pocket maximums Any cost-sharing payments made pursuant to subsection (a)(2) shall be counted toward any deductible or out-of-pocket maximum that applies under the plan or coverage. . (b) No effect on other cost-Sharing Section 1302(d)(2) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(d)(2) (D) Special rule relating to insulin coverage For plan years beginning on or after January 1, 2024, the exemption of coverage of selected insulin products (as defined in section 2799A–11(b) of the Public Health Service Act) from the application of any deductible pursuant to section 2799A–11(a)(1) of such Act, section 726(a)(1) of the Employee Retirement Income Security Act of 1974, or section 9826(a)(1) . (c) Coverage of certain insulin products under catastrophic plans Section 1302(e) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(e) (4) Coverage of certain insulin products (A) In general Notwithstanding paragraph (1)(B)(i), a health plan described in paragraph (1) shall provide coverage of selected insulin products, in accordance with section 2799A–11 of the Public Health Service Act, for a plan year before an enrolled individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c)(1) for the plan year. (B) Terminology For purposes of subparagraph (A)— (i) the term selected insulin products (ii) the requirements of section 2799A–11 of such Act shall be applied by deeming each reference in such section to individual health insurance coverage . (d) ERISA (1) In general Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185 et seq. 726. Requirements with respect to cost-sharing for certain insulin products (a) In general For plan years beginning on or after January 1, 2024, a group health plan or health insurance issuer offering group health insurance coverage shall provide coverage of selected insulin products, and with respect to such products, shall not— (1) apply any deductible; (2) impose any cost-sharing requirement in excess of the lesser of, per 30-day supply— (A) $25; or (B) the amount equal to 25 percent of the negotiated price of the selected insulin product net of all price concessions received by or on behalf of the plan or coverage, including price concessions received by or on behalf of third-party entities providing services to the plan or coverage, such as pharmacy benefit management services; or (3) impose any utilization management practices such as prior authorization, step therapy protocols, or other similar conditions on such products, except as clinically justified and as specified by the Secretary. (b) Definitions In this section: (1) Selected insulin products The term selected insulin products (2) Insulin defined The term insulin 42 U.S.C. 262 (c) Out-of-Network providers Nothing in this section requires a plan or issuer that has a network of providers to provide benefits for selected insulin products described in this section that are delivered by an out-of-network provider, or precludes a plan or issuer that has a network of providers from imposing higher cost-sharing than the levels specified in subsection (a) for selected insulin products described in this section that are delivered by an out-of-network provider. (d) Rule of construction Subsection (a) shall not be construed to require coverage of, or prevent a group health plan or health insurance coverage from imposing cost-sharing other than the levels specified in subsection (a) on, insulin products that are not selected insulin products, to the extent that such coverage is not otherwise required and such cost-sharing is otherwise permitted under Federal and applicable State law. (e) Application of cost-Sharing towards deductibles and out-of-Pocket maximums Any cost-sharing payments made pursuant to subsection (a)(2) shall be counted toward any deductible or out-of-pocket maximum that applies under the plan or coverage. . (2) Clerical amendment The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1001 et seq. Sec. 726 Requirements with respect to cost-sharing for certain insulin products. . (e) Internal Revenue Code (1) In general Subchapter B of chapter 100 9826. Requirements with respect to cost-sharing for certain insulin products (a) In general For plan years beginning on or after January 1, 2024, a group health plan shall provide coverage of selected insulin products, and with respect to such products, shall not— (1) apply any deductible; (2) impose any cost-sharing requirement in excess of the lesser of, per 30-day supply— (A) $25; or (B) the amount equal to 25 percent of the negotiated price of the selected insulin product net of all price concessions received by or on behalf of the plan, including price concessions received by or on behalf of third-party entities providing services to the plan, such as pharmacy benefit management services; or (3) impose any utilization management practices such as prior authorization, step therapy protocols, or other similar conditions on such products, except as clinically justified and as specified by the Secretary. (b) Definitions In this section: (1) Selected insulin products The term selected insulin products (2) Insulin defined The term insulin 42 U.S.C. 262 (c) Out-of-Network providers Nothing in this section requires a plan that has a network of providers to provide benefits for selected insulin products described in this section that are delivered by an out-of-network provider, or precludes a plan that has a network of providers from imposing higher cost-sharing than the levels specified in subsection (a) for selected insulin products described in this section that are delivered by an out-of-network provider. (d) Rule of construction Subsection (a) shall not be construed to require coverage of, or prevent a group health plan from imposing cost-sharing other than the levels specified in subsection (a) on, insulin products that are not selected insulin products, to the extent that such coverage is not otherwise required and such cost-sharing is otherwise permitted under Federal and applicable State law. (e) Application of cost-Sharing towards deductibles and out-of-Pocket maximums Any cost-sharing payments made pursuant to subsection (a)(2) shall be counted toward any deductible or out-of-pocket maximum that applies under the plan. . (2) Clerical amendment The table of sections for subchapter B of chapter 100 of such Code is amended by adding at the end the following new item: Sec. 9826 Requirements with respect to cost-sharing for certain insulin products. . (f) Implementation The Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury shall implement the provisions of this section, including the amendments made by this section, through subregulatory guidance or program instruction.

Summary: Cap Insulin Prices Act This bill reduces cost-sharing for insulin under private health insurance and the Medicare prescription drug benefit. Specifically, the bill caps cost-sharing under private health insurance for a month's supply of selected insulin products at $25 or 25% of a plan's negotiated price (after any price concessions), whichever is less, beginning in 2024. The bill caps cost-sharing under the Medicare prescription drug benefit for a month's supply insulin products at $25 beginning in 2024. The current cap on insulin products under Medicare is $35 per month.