- βReduces insulin costs to $35/month for Medicare enrollees
- βCovers all FDA-approved insulin types under Medicare Part D
- βCan be combined with FSA/HSA savings for additional diabetes expense relief
What Is the $35 Insulin Price Cap?
For millions of Americans living with diabetes, the cost of insulin has long been a source of financial stress and, in many cases, life-threatening rationing. The $35 insulin price cap β established through the Inflation Reduction Act of 2022 β represents a landmark shift in how insulin is priced and accessed in the United States. But understanding exactly what the cap covers, and who benefits, is essential for every person managing diabetes.
Who Does the $35 Cap Apply To?
As of January 2023, the $35 monthly cap on insulin applies to all Medicare Part D enrollees and Medicare Advantage plans that include prescription drug coverage. This means that seniors and certain individuals with disabilities who are enrolled in Medicare cannot be charged more than $35 per month for covered insulin products, regardless of where they fall in the coverage phases of their plan β including the coverage gap (formerly called the "donut hole").
It is important to note that as of now, the $35 cap does not automatically apply to private insurance plans. However, many major private insurers β including CVS Caremark, Express Scripts, and others β have voluntarily adopted similar caps following public and legislative pressure. Always check with your specific insurer to confirm your plan's policy.
What Types of Insulin Are Covered?
Under the Medicare rule, the $35 cap applies to all insulin products covered under Medicare Part D, including:
- Rapid-acting insulin (such as Humalog, NovoLog, and Fiasp)
- Long-acting insulin (such as Lantus, Basaglar, and Toujeo)
- Intermediate-acting insulin
- Biosimilar insulins approved by the FDA
- Inhaled insulin (such as Afrezza, where covered)
The cap applies per month's supply, meaning if you use multiple types of insulin, each qualifies for the $35 limit individually under your covered plan.
What About Insulin Devices and Supplies?
The $35 rule specifically targets insulin itself. Insulin pens, syringes, continuous glucose monitors (CGMs), and insulin pumps are not included in the price cap legislation. These supplies may still be subject to standard deductibles and co-pays. Resources like mdsdiabetes.com offer practical guidance on managing the full spectrum of diabetes-related costs, including how to use FSA and HSA accounts to cover supplies not protected under the cap.
FSA and HSA Strategies to Pair with the Price Cap
Even with the $35 cap in place, diabetes management costs add up quickly. Pairing your insulin savings with a Flexible Spending Account (FSA) or Health Savings Account (HSA) can dramatically reduce your out-of-pocket burden for everything the cap doesn't cover. Use your FSA or HSA for:
- Blood glucose meters and test strips
- Insulin pump supplies and CGM sensors
- Lancets and pen needles
- Diabetes education programs
What to Do If You're Struggling With Insulin Costs
If you are uninsured or on a private plan that hasn't adopted a $35 cap, you still have options. Manufacturer patient assistance programs from Eli Lilly, Novo Nordisk, and Sanofi offer deeply discounted or free insulin to qualifying individuals. Generic and biosimilar insulins are also increasingly available at reduced prices.
Always consult your healthcare provider or a certified diabetes educator before switching insulin brands or adjusting doses for cost reasons.
The Bottom Line
The $35 insulin price cap is a major victory for the diabetes community, particularly Medicare enrollees. Understanding its scope β and its limitations β empowers you to plan smarter and advocate for broader coverage. Stay informed, explore all available resources, and take control of your diabetes management costs.