H.R. 2636: Making Insulin Affordable for All Children Act

The rule is simple at the counter. If you're 26 or younger and on a private plan, a 30-day supply of your plan's covered insulin would cost you no more than $35 — and the plan could not make you meet your deductible first.

The cap can be lower than $35. You'd pay whichever is less: $35, or 25% of the price your plan actually pays for the insulin after rebates and discounts, including those negotiated by pharmacy benefit managers. If your plan's net cost for a vial is $60, a quarter of that is $15 — so $15 is your ceiling.

Plans choose which insulins get the cap, but the choice has a floor. They must cover at least one product in each type of insulin (rapid-acting, short-acting, intermediate, long-acting, ultra long-acting and premixed) in each available form, such as vials, pumps or inhalers. A brand outside the plan's picks can still carry normal cost-sharing.

Turn 27, and the guaranteed cap goes away — the bill leaves older patients' costs to their plan and to whatever state law already requires.

What you pay under the cap still counts toward your deductible and out-of-pocket maximum, so a family isn't penalized later in the year for getting a lower price up front. The same rules reach employer plans, individual policies and catastrophic plans, which would have to cover the insulin before a young enrollee hits the plan's high spending threshold.