Calendar Year 2026 Insulin Prescription Caps

BULLETIN 2025-3 4315 South 2700 West, Suite 2300, Taylorsville, Utah 84129 ● Office (801) 957-9200 ● Facsimile (385) 465-6047 ● insurance.utah.gov State of Utah SPENCER J. COX Governor DEIDRE M. HENDERSON Lieutenant Governor Insurance Department JONATHAN T. PIKE Insurance Commissioner To: Insurers Offering a Health Benefit Plan From: Jonathan T. Pike, Insurance Commissioner Date: February 5, 2025 Subject: Calendar Year 2026 Insulin Prescription Caps The Utah Insurance Department issues this Bulletin under Utah Code § 31A-22-626, Coverage of Diabetes, and Utah Admin. Code R590-200, Diabetes Treatment and Management. This Bulletin notifies an insurer offering a health benefit plan of the annual inflation adjustment cap to the average wholesale price for insulin. A policy issued or renewed during the 2026 calendar year with a 30-day prescription supply must offer at least one insulin in each therapy category. A 30-day prescription supply cap is set at $10.00 for § 31A-22-626(4)(a) and $35.00 for § 31A-22-626(6)(b). The insulin cap is calculated using data provided by the Public Employees Health Plan (PEHP). PEHP calculated the Average Wholesale Price per Milliliter (AWP/mL) of insulin for calendar years 2019 through 2024. PEHP included all insulin modes and therapy categories in the calculation. For 2026 plans, the $30 and $100 caps in place for 2021 are adjusted as follows: 2026 cap = (2024 Avg AWP/mL / 2019 Avg AWP/mL) * Base Cap or 2026 low cap = (14.54 / 40.18) * $30 = $10.85, rounded down to the nearest multiple of five dollars = $10 Calendar Year Avg AWP/mL % change in AWP/mL 2019 $40.18 n/a 2020 $37.85 -5.8% 2021 $36.31 -4.1% 2022 $36.83 1.5% 2023 $37.64 2.2% 2024 $14.54 -61.4% 2026 high cap = (14.54 / 40.18) * $100 = $36.19, rounded down to the nearest multiple of five dollars = $35 The annual price of insulin through the Utah Insulin Savings Program, under § 31A-22-626(6)(a), is available at https://www.utahinsulin.net/. An insurer with questions about this Bulletin is advised to contact the Health and Life Division at health.uid@utah.gov. DATED this 5th day of February 2025. _________________________________ Jonathan T. Pike Insurance Commissioner