The $35 Medicare Insulin Cap: How It Works, Who Qualifies, and What Is Covered in 2026

What Is the Medicare $35 Insulin Cap?

The $35 insulin cap is a provision of the Inflation Reduction Act (IRA) that limits how much Medicare beneficiaries pay out of pocket for insulin to no more than $35 per month per covered insulin product. Before this cap took effect in January 2023, many Medicare enrollees paid $100 to $400 or more per month for insulin, depending on their plan's formulary tier and cost-sharing structure. According to CMS, approximately 3.4 million Medicare beneficiaries use insulin, and the cap saves the average insulin user more than $500 per year.

The cap is not optional or plan-specific. Every Medicare Part D plan and every Medicare Advantage plan with drug coverage must comply with the $35 limit. You do not need to apply for the cap, enroll in a special program, or use a manufacturer coupon. It is automatic for all covered insulin products on your plan's formulary.

How the $35 Cap Works at the Pharmacy

When you fill an insulin prescription at the pharmacy, your plan automatically applies the $35 cap at the point of sale. You will never see a higher cost on the register for a covered insulin product, regardless of what coverage phase you are in (deductible, initial coverage, or coverage gap). Here is how it works in practice:

Which Insulin Products Are Covered?

The $35 cap applies to all insulin products that are on your specific plan's formulary (covered drug list). This includes brand-name insulins, biosimilar insulins, and authorized generics across all delivery methods.

Covered Insulin Types

• Rapid-acting insulin (Humalog, NovoLog, Fiasp, Admelog, Lyumjev, and biosimilars)

• Short-acting insulin (Humulin R, Novolin R)

• Intermediate-acting insulin (Humulin N, Novolin N)

• Long-acting insulin (Lantus, Basaglar, Levemir, Tresiba, Toujeo, Semglee, and biosimilars)

• Pre-mixed insulin combinations (Humalog Mix, NovoLog Mix, Humulin 70/30)

• Concentrated insulins (Humulin R U-500, Toujeo Max)

Covered Delivery Methods

• Insulin vials (for use with syringes)

• Insulin pens (pre-filled and reusable)

• Insulin cartridges (for compatible pen devices)

• Insulin for use in pumps (covered under Part B, not Part D)

If your preferred insulin product is not on your plan's formulary, the $35 cap does not apply to it. However, you can request a formulary exception from your plan, switch to a covered alternative, or change plans during the Annual Enrollment Period to one that covers your specific insulin.

Part B Insulin Coverage (Insulin Pumps)

If you use an insulin pump, your insulin is covered under Medicare Part B rather than Part D. The $35 monthly cap still applies to Part B insulin, but the billing works differently. Instead of paying at the pharmacy, your Part B insulin is typically supplied through a durable medical equipment (DME) supplier. The $35 cap applies per month of supply, and your DME supplier should apply it automatically.

Part B also covers the insulin pump itself, pump supplies (infusion sets, reservoirs, and batteries), and the insulin to fill it. The $35 cap applies only to the insulin portion, not to the pump hardware or supplies, which remain subject to standard Part B cost-sharing (20% coinsurance after the $283 annual deductible in 2026).

💡 Eddie's Pro Tip

If you are paying more than $35 for insulin at the pharmacy, something is wrong. Either the specific product is not on your plan's formulary, or the pharmacy's system has not been updated correctly. Do not just pay the higher amount. Ask the pharmacist to reprocess the claim, call your plan's member services number, or contact 1-800-MEDICARE. I have seen cases where a simple reprocessing at the pharmacy counter fixed the issue immediately. You should never pay more than $35 for a covered insulin product under Medicare.

The $35 Cap and the $2,000 Annual Out-of-Pocket Limit

The $35 you pay each month for insulin counts toward your Part D annual out-of-pocket cap of $2,000. If you take insulin plus other expensive medications, your combined spending will eventually reach the $2,000 limit, at which point you pay $0 for all covered Part D drugs (including insulin) for the rest of the year. For beneficiaries who only take insulin and no other expensive drugs, the $35 monthly cap means you would spend a maximum of $420 per year on insulin ($35 x 12 months), well below the $2,000 annual limit.

What If You Use Multiple Insulin Products?

Many people with diabetes use two or more insulin products, such as a long-acting basal insulin (like Lantus or Tresiba) plus a rapid-acting mealtime insulin (like Humalog or NovoLog). The $35 cap applies separately to each covered insulin product per month. This means if you use two different insulins, your maximum monthly insulin cost is $70 ($35 for each product), not $35 total.

However, if you fill a 90-day supply of insulin through a mail-order pharmacy, the $35 cap applies per month of supply within that fill. A 90-day supply would cost you a maximum of $105 ($35 x 3 months), which is the same as filling monthly at a retail pharmacy.

Who Does NOT Qualify for the $35 Cap?

The $35 insulin cap is specific to Medicare. It does not apply to people with private insurance, employer coverage, or individual ACA marketplace plans (though some states have enacted their own insulin caps for commercial insurance). Additionally, the cap does not apply if:

• You do not have Medicare Part D or a Medicare Advantage plan with drug coverage

• Your specific insulin product is not on your plan's formulary

• You purchase insulin from a pharmacy outside your plan's network

• You are buying insulin without using your Medicare drug benefit (paying cash)

Frequently Asked Questions About the Medicare Insulin Cap

Frequently Asked Questions