Is Insulin Still $35 on Medicare in 2026? Agent Guide

Agents are still running into a practical Medicare Part D question:

An agent enters Lantus, Humalog, NovoLog, or another insulin into Medicare Plan Finder or a quoting tool. The plan shows the insulin on a tier with 25% coinsurance instead of showing a clean $35 copay. The agent then wonders:

Is the client actually going to pay 25%, or is the insulin capped at $35?

The practical answer is:

That sounds simple, but the field workflow still needs care. The $35 cap does not mean every insulin product is covered by every Part D plan, and it does not remove the need to check the exact product, dosage, form, pharmacy, and plan formulary.

For the broader 2026 drug-plan context, use this mini-post with the larger 2026 Medicare Part D changes guide for agents. This article focuses only on how the Medicare insulin cap works in 2026.

Is insulin still capped at $35 on Medicare?

Yes. Medicare’s insulin cost-sharing cap is still in effect.

Medicare.gov says the cost of a one-month supply of each Part B- and Part D-covered insulin product is no more than $35, and the deductible does not apply to insulin. Medicare.gov also says that, if a beneficiary gets a three-month supply of covered insulin, the cost generally cannot exceed $35 for each month’s supply, or $105 for a three-month supply.

That is the client-friendly rule. For agents, the key is explaining the coverage condition behind it.

The key phrase is “covered insulin product”

The $35 cap does not mean every insulin is automatically covered by every Part D plan.

CMS’s insulin FAQ explains that, under a Medicare Part D prescription drug plan, the $35 cap applies when an insulin is a covered insulin product. CMS says a covered insulin product is one included on a Part D sponsor’s formulary, and an insulin product may also be considered covered in other instances.

For agents, that means there are two different questions:

The client-facing explanation should be:

That is more accurate than saying: “All insulin is $35.” It is also more useful than saying: “The plan shows 25%, so you may owe 25% of whatever the retail price is.”

Why does a formulary or quoting tool show 25% coinsurance?

This is where agents are getting stuck.

Some formularies and quoting tools may display insulin like a normal Part D drug: tier number, cost-sharing type, and percentage coinsurance. For example, an insulin might show as Tier 3 with 25% coinsurance.

That display can be confusing because, for 2026 and later years, CMS codified the insulin rule differently. CMS says the Part D deductible does not apply to covered insulin products, and the cost-sharing amount for a one-month supply must not exceed the applicable covered insulin cost-sharing amount. For 2026 and later, that amount is the lesser of $35, 25% of the maximum fair price if applicable, or 25% of the plan’s negotiated price.

In plain English:

The Federal Register addressed this kind of issue. CMS clarified that if a Part D sponsor places a covered insulin product on a tier with a copayment or coinsurance higher than the statutory maximum, the sponsor still has to apply the covered insulin cost-sharing limit. CMS gave examples where a $50 copay or 30% coinsurance could not override the insulin cap.

That is the line agents should remember:

What is the 2026 Medicare insulin rule?

For 2026 and later years, the applicable cost-sharing amount for a covered insulin product is the lesser of:

1. $35;
2. 25% of the maximum fair price, if the insulin is subject to Medicare drug price negotiation; or
3. 25% of the plan’s negotiated price for that covered insulin product.

That means the client may pay less than $35 in some situations.

For agents, the rule is not technically “always $35.” The better phrasing is:

That is accurate, simple, and defensible.

Does the deductible apply to insulin?

No. For covered insulin products, the Part D deductible does not apply.

Medicare.gov says beneficiaries do not have to pay a deductible for insulin. CMS’s 2026 final rule fact sheet also states that the Part D deductible does not apply to covered insulin products.

The eCFR rule is direct: for covered insulin products, a Part D sponsor must not apply a deductible and must ensure cost-sharing for each fill up to a one-month supply does not exceed the covered insulin cost-sharing amount.

This is important during plan comparisons because a client may see a $615 Part D deductible in 2026 and assume the insulin is subject to that deductible.

A good agent script:

Are all insulins capped at $35?

Not automatically.

The cap applies to covered insulin products. That means the agent still needs to verify:

• the exact insulin name;
• dosage;
• delivery form, such as vial, pen, inhaled insulin, or pump-related insulin;
• whether the product is on the plan formulary;
• whether prior authorization, quantity limits, or other utilization management applies;
• whether the pharmacy is in network;
• whether the client is using Part B or Part D coverage.

For example, Humalog KwikPen, Lantus SoloStar, NovoLog FlexPen, insulin lispro, insulin glargine, and other products may not be treated the same way by every plan. One plan may cover a specific insulin pen, while another plan may prefer a different insulin product or formulation.

The $35 rule does not eliminate the need to check the formulary. It means that once the insulin is covered, the member’s cost-sharing for a one-month supply should not exceed the insulin cost-sharing limit.

What should agents do when a tool shows 25%?

When Medicare Plan Finder or another quoting tool shows 25% coinsurance for insulin, agents should not automatically assume the member will owe unlimited 25% of the drug’s retail price.

Use this workflow instead.

Step 1: Confirm whether the insulin is covered

Check whether the exact insulin product is on the plan formulary. Do not just search “insulin.” Confirm the specific product and form.

Examples:

• Lantus vial vs. Lantus SoloStar;
• Humalog vial vs. Humalog KwikPen;
• NovoLog vial vs. NovoLog FlexPen;
• insulin lispro vial vs. insulin lispro pen.

Small differences matter.

Step 2: Confirm whether the pharmacy is in network

Pharmacy status can affect pricing and plan displays. Make sure the client’s preferred pharmacy is selected and confirm whether it is preferred, standard, or out of network.

CMS’s insulin FAQ says the cap applies at both preferred and non-preferred pharmacies under an individual’s prescription drug plan, but pharmacy status can still matter for other drugs and for the overall plan review.

Step 3: Apply the Medicare insulin rule

If the insulin is covered, the cost-sharing limit applies. The member should pay no more than the applicable cap for a one-month supply.

For most client explanations, that means saying:

Step 4: Verify with the carrier when the display conflicts with the rule

If a tool shows a number that appears inconsistent with Medicare’s insulin cap, verify directly with the carrier or enrollment platform before telling the client a final cost.

The agent should document:

• tool used;
• date checked;
• plan name;
• drug name and dosage;
• pharmacy;
• whether the drug appeared covered;
• what cost-sharing was shown;
• any carrier verification received.

Step 5: Set expectations with the client

Use careful language:

That is better than overpromising or ignoring the discrepancy.

Client-facing explanation agents can use

Here is a simple script agents can use when a client asks why their insulin shows 25%:

That script gives the client confidence without making an unsupported claim.

What agents should not say

Avoid saying:

• “All insulin is $35.”
• “The tool shows 25%, so that is definitely what you will pay.”
• “Plan Finder is wrong.”

The last one is too casual and may not be accurate. The issue may be the way tier, negotiated price, formulary status, days’ supply, pharmacy, or cost-sharing fields are displayed.

A better explanation is:

Quick FAQ for agents

Is Medicare insulin still $35 in 2026?

Yes. For each Part B- or Part D-covered insulin product, Medicare.gov says the cost of a one-month supply is no more than $35, and the deductible does not apply.

Can the client pay less than $35?

Yes. For 2026 and later years, the cost-sharing amount is the lesser of $35, 25% of the maximum fair price if applicable, or 25% of the plan’s negotiated price.

Does the $35 cap apply to non-formulary insulin?

Not automatically. The cap applies to covered insulin products. CMS explains that a covered insulin product is one included on a Part D sponsor’s formulary, and an insulin product may also be considered covered in other instances.

Does the Part D deductible apply to insulin?

No. The Part D deductible does not apply to covered insulin products.

What if a formulary shows insulin as Tier 3 with 25% coinsurance?

That does not automatically mean the client will pay unlimited 25%. If it is a covered insulin product, the plan still must apply the insulin cost-sharing limit.

Does the cap apply at preferred and non-preferred pharmacies?

CMS’s insulin FAQ says yes, the cap applies at both preferred and non-preferred pharmacies under an individual’s prescription drug plan.

Does the cap apply to a three-month supply?

Yes, but it is applied by monthly supply amount. Medicare.gov says a three-month supply generally cannot be more than $35 for each month’s supply of each covered insulin product, meaning generally no more than $105 for a three-month supply.

Bottom line for agents

If a Medicare Part D plan shows insulin as covered but displays a tier or 25% coinsurance, do not stop there.

The agent’s job is to confirm whether the exact insulin product is covered, confirm the pharmacy, and then apply the Medicare insulin rule.

For a covered insulin product, the client’s cost for a one-month supply should be capped at $35 or less, and the deductible should not apply.

That is the message agents should understand, document, and explain clearly.

Sources

• Insulin coverage: Medicare.gov Accessed 2026-06-23.
• Frequently Asked Questions about Medicare Insulin Cost-Sharing Changes: Centers for Medicare & Medicaid Services Accessed 2026-06-23.
• Contract Year 2026 Medicare Advantage and Part D Final Rule Fact Sheet: Centers for Medicare & Medicaid Services Accessed 2026-06-23.
• 42 C.F.R. 423.100 - Part D definitions: Electronic Code of Federal Regulations Accessed 2026-06-23.
• 42 C.F.R. 423.104 - Qualified prescription drug coverage requirements: Electronic Code of Federal Regulations Accessed 2026-06-23.
• Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes: Federal Register Accessed 2026-06-23.

Frequently Asked Questions

Is Medicare insulin still $35 in 2026?

Yes. Medicare.gov says the cost of a one-month supply of each Part B- and Part D-covered insulin product is no more than $35, and the deductible does not apply to insulin.

Can a Medicare client pay less than $35 for covered insulin?

Yes. For 2026 and later years, the cost-sharing amount for a covered insulin product is the lesser of $35, 25% of the maximum fair price if applicable, or 25% of the plan's negotiated price.

Does the Medicare insulin cap apply to non-formulary insulin?

Not automatically. The insulin cap applies to covered insulin products. Agents still need to confirm that the exact insulin product and form are covered by the plan.

Does the Part D deductible apply to covered insulin products?

No. CMS and Medicare.gov state that the Part D deductible does not apply to covered insulin products.

What if a formulary shows insulin as Tier 3 with 25% coinsurance?

That display does not automatically mean the client will pay unlimited 25%. If the insulin is a covered insulin product, the plan still has to apply the covered insulin cost-sharing limit.

Does the insulin cap apply at preferred and non-preferred pharmacies?

CMS's insulin FAQ says yes, the cap applies at both preferred and non-preferred pharmacies under an individual's prescription drug plan.

Does the insulin cap apply to a three-month supply?

Yes, but it is applied by monthly supply amount. Medicare.gov says a three-month supply generally cannot exceed $35 for each month's supply of each covered insulin product.