Georgia Medicare $35 Insulin Cap: Federal Framework and Implementation

For Georgia Medicare beneficiaries with diabetes, the Inflation Reduction Act of 2022 delivered one of the most concrete and immediately tangible reforms in the Medicare program's history: a $35 monthly cap on out-of-pocket cost-sharing for covered insulin. Before the cap took effect on January 1, 2023, Georgia retirees commonly paid $200 to $500 per month for insulin at the pharmacy counter, with specialty insulin formulations or multi-insulin regimens often exceeding $700 per month. Patient surveys, news reporting, and federal data from the years leading up to the IRA documented Medicare beneficiaries rationing insulin (skipping doses, splitting vials, stretching pens) to make ends meet on fixed retirement income.

Georgia Medicare $35 Insulin Cap at a glance

• Federal authority: Section 11406 of the Inflation Reduction Act 2022 (Public Law 117-169), implemented through Section 1860D-2(b)(8) of the Social Security Act for Part D and Section 1833(t)(15) for Part B insulin pumps. 42 CFR 423.104(d)(2) and 42 CFR 410.29 contain implementing regulations.
• Effective date: January 1, 2023, for Part D covered insulin; July 1, 2023, for Part B insulin pump and supplies.
• Cap amount: $35 per 30-day supply (or $70 for 60-day, $105 for 90-day). The cap applies separately to each covered insulin product, not in aggregate across all insulin.
• Deductible waiver: Beneficiaries do NOT have to satisfy the annual Part D deductible before receiving the $35 cap. Insulin cost is fixed at $35 from January 1.
• Coverage scope: All insulin on the plan formulary (long-acting, rapid-acting, intermediate, concentrated, mixed, vial, pen formulations, branded and biosimilar).
• Not covered by cap: Out-of-network pharmacy fills, drugs not on formulary, OTC retail (e.g., Walmart ReliOn without plan claim), cash purchases outside Medicare.
• Interaction with IRA reforms: Insulin payments count toward the $2,000 OOP cap (Section 11201).
• For Georgia families: GeorgiaCares (1-866-552-4464) provides free counseling on insulin coverage. The cap saves typical Georgia insulin users $3,000 to $6,000 per year compared to pre-2023 costs.

By Brevy Care Team · Last verified May 13, 2026

The $35 cap, codified at Section 11406 of the Inflation Reduction Act (Public Law 117-169) and operationalized through amendments to Section 1860D-2(b)(8) of the Social Security Act (for Part D) and Section 1833(t)(15) of the Social Security Act (for Part B insulin pumps), ended that calculus for millions of Medicare beneficiaries, including Georgia retirees. The cap applies regardless of plan, deductible status, formulary tier, or coverage phase. From January 1, 2023, a Georgia beneficiary picking up Lantus at an in-network pharmacy paid no more than $35 for a 30-day supply, even before satisfying the Part D annual deductible.

This guide explains the federal statutory and regulatory framework for the Medicare insulin cap, walks through the operational mechanics from claims processing to pharmacy counter, details what insulin products and supply sizes are covered (and what is not), examines the cap's interaction with the other major Inflation Reduction Act reforms (the $2,000 out-of-pocket cap, the Medicare Prescription Payment Plan, and the Medicare Drug Price Negotiation Program), provides historical context on the pre-IRA insulin pricing landscape, and offers six worked examples showing concrete dollar savings for typical Georgia Medicare insulin users.

Federal framework: Section 11406 and the structural insulin cost-sharing cap

To understand how the $35 cap operates in Georgia, it helps to start with the statutory architecture Congress built into the Inflation Reduction Act. Section 11406 of the IRA accomplished two distinct things. First, it added new subsection (8) to Section 1860D-2(b) of the Social Security Act, capping Part D beneficiary cost-sharing on "covered insulin product" at no more than $35 per 30-day supply. Second, it added subsection (15) to Section 1833(t) of the Social Security Act, applying the same $35 cap to Part B insulin delivered through external insulin pumps that qualify as durable medical equipment (DME).

These two provisions cover essentially all Medicare beneficiary access to insulin. Insulin used outside an insulin pump is covered under Part D; insulin used inside an insulin pump is covered under Part B because the pump itself is DME. By capping both pathways at $35, Congress ensured Georgia Medicare beneficiaries on any insulin therapy receive consistent cost protection.

Section 1860D-2(b)(8): Part D operational provisions

The Part D cap, at Section 1860D-2(b)(8) of the Social Security Act and 42 CFR 423.104(d)(2), requires every Medicare Part D plan (both standalone PDPs and Medicare Advantage MA-PDs) to:

• Charge no more than $35 for a 30-day supply of covered insulin
• Charge no more than $70 for a 60-day supply
• Charge no more than $105 for a 90-day supply
• Apply the cap regardless of formulary tier (Tier 3 brand, Tier 5 specialty, or any other)
• Apply the cap regardless of coverage phase (deductible, initial coverage, or catastrophic)
• Apply the cap from January 1 each year : no annual deductible to satisfy first

The cap applies per insulin product. A Georgia beneficiary prescribed both a rapid-acting insulin (Humalog) and a long-acting insulin (Lantus) pays $35 for each, totaling $70 per month. This is by design: a two-insulin regimen is medically distinct from a single-insulin regimen, so each prescription gets its own cap.

Section 1833(t)(15): Part B insulin pump cap

The Part B cap, at Section 1833(t)(15) of the Social Security Act and 42 CFR 410.29, applies to insulin delivered through an external insulin pump that is a Medicare-covered DME item. The pump itself is covered under Part B's DME benefit. The insulin used in the pump is also covered under Part B (not Part D). The cap on the pump insulin took effect July 1, 2023 (six months after the Part D cap).

Section 1833(b)(11) waives the Part B deductible for insulin pump insulin, so beneficiaries pay $35 from the first 30-day supply each year, without satisfying the $283 Part B deductible (2026) first.

Section 1860D-2(b)(2)(D): Deductible waiver

For Part D, Section 1860D-2(b)(2)(D) of the Social Security Act, added by IRA Section 11406, waives the Part D annual deductible for covered insulin. In 2026, that means the annual Part D deductible does not apply to insulin claims. A Georgia beneficiary who picks up Lantus on January 2 pays $35, not the full deductible plus $35.

This deductible waiver is significant because most Part D plans require beneficiaries to satisfy the deductible at the start of the year. Without the waiver, Georgia insulin users would face a full deductible bill in January before the $35 cap kicked in. The deductible waiver eliminates that frontloaded burden entirely for insulin.

Coverage scope: what insulin is covered by the cap

The $35 cap applies broadly to insulin products on the plan formulary. Specifically:

Long-acting insulins covered

• Lantus (insulin glargine) by Sanofi
• Toujeo (insulin glargine U-300) by Sanofi
• Basaglar (insulin glargine biosimilar) by Lilly
• Semglee (insulin glargine biosimilar) by Mylan/Biocon
• Levemir (insulin detemir) by Novo Nordisk
• Tresiba (insulin degludec) by Novo Nordisk

Rapid-acting insulins covered

• Humalog (insulin lispro) by Lilly
• Lyumjev (insulin lispro-aabc) by Lilly
• Novolog (insulin aspart) by Novo Nordisk
• Fiasp (insulin aspart faster) by Novo Nordisk
• Apidra (insulin glulisine) by Sanofi
• Admelog (insulin lispro biosimilar) by Sanofi

Intermediate-acting insulins covered

• Humulin N (NPH insulin) by Lilly
• Novolin N (NPH insulin) by Novo Nordisk

Concentrated insulins covered

• Humalog U-200 (lispro 200 units/mL) by Lilly
• Toujeo U-300 (glargine 300 units/mL) by Sanofi
• Tresiba U-200 (degludec 200 units/mL) by Novo Nordisk

Mixed (pre-mixed) insulins covered

• Humulin 70/30, Humalog Mix 75/25, Humalog Mix 50/50 by Lilly
• Novolin 70/30, NovoLog Mix 70/30 by Novo Nordisk

Vial and pen formulations both covered

The cap applies whether the insulin is dispensed as vials (for syringe-injection users) or as prefilled pens (FlexPen, KwikPen, FlexTouch, SoloStar, Solostar, Touchpod, etc.). Pens often cost more at list price but the beneficiary still pays $35.

What is NOT covered by the cap

• Insulin not on the plan formulary: A Georgia beneficiary whose insulin is not on the plan's drug list cannot get the cap. The beneficiary or physician must request a formulary exception under Section 1860D-4(g) and 42 CFR 423.578, or switch to a covered alternative.
• Out-of-network pharmacy fills: Part D plans pay for drugs filled at in-network pharmacies. An out-of-network fill (except emergencies) is not covered, and the $35 cap does not apply.
• Over-the-counter retail purchases without Medicare claim: Walmart's ReliOn brand and certain regular human insulins (NPH and Regular) are technically available without a prescription. If purchased outside the Medicare benefit (no claim processed through the plan), the cap does not apply.
• Cash purchases at any pharmacy outside Medicare: If the beneficiary pays cash without using their Part D card, the cap does not apply.
• Insulin under non-Medicare insurance: The cap applies only to Medicare. Beneficiaries with commercial insurance or Medicaid coverage of insulin are not subject to this specific federal cap (though some states and plans have similar protections).

Operational mechanics: how the cap works in practice

At the Part D plan level

Each Medicare Part D plan must configure its claims processing system to identify covered insulin products by National Drug Code (NDC) and apply the $35 cap automatically. The plan handles all the arithmetic: full list price → manufacturer rebates and PBM negotiations → plan-level cost → beneficiary share capped at $35.

The plan absorbs the difference between what it would have charged the beneficiary at standard cost-sharing rates and the $35 cap. Plans build this cost into their bid for Part D contracts. CMS factors the cap into plan reimbursement.

At the Part B level for insulin pumps

For Part B insulin pumps, the DME supplier bills Medicare directly. Beneficiaries pay $35 for the 30-day insulin supply. The pump itself (the equipment) is separately billed; the cap applies to the insulin, not the pump.

At the pharmacy counter in Georgia

Georgia pharmacies (CVS, Walgreens, Walmart, Kroger, Publix, Rite Aid, independent community pharmacies) process insulin claims through the standard Part D claim system. When a Medicare beneficiary presents an insulin prescription:

1. Pharmacy enters the prescription into its system
2. Claim transmits to the Part D plan's PBM
3. Plan identifies the drug as covered insulin
4. Plan calculates plan-level cost and applies $35 cap
5. Pharmacy displays $35 (or less for LIS recipients) to the beneficiary
6. Beneficiary pays $35
7. Pharmacy receives full reimbursement from the plan
8. Plan recovers manufacturer rebates and government reinsurance through its bid

The entire process is automatic. Georgia beneficiaries do not need to apply, request, or notify the plan about the cap. It applies by default for any in-network covered insulin fill.

What beneficiaries see

A Georgia Medicare beneficiary picking up insulin sees:

• Pharmacy receipt: $35 (or less if LIS-eligible)
• Same amount every month, every year
• No deductible at start of year
• Same $35 at any in-network pharmacy in Georgia (CVS, Walgreens, Walmart, etc.)

Interaction with other Inflation Reduction Act reforms

The $35 insulin cap operates alongside three other major IRA Part D reforms. Understanding how they interact helps Georgia families plan their drug coverage.

Interaction with the $2,000 out-of-pocket cap (IRA Section 11201)

Insulin cost-sharing counts toward the $2,000 annual out-of-pocket cap under Section 11201, codified at Section 1860D-2(b) as restructured by IRA. A Georgia beneficiary paying $35/month for insulin contributes $420/year ($35 × 12) toward the $2,000 cap. For a beneficiary on a single insulin and no other high-cost drugs, $420 toward the $2,000 cap is unlikely to hit the cap.

For a beneficiary on multiple insulins, or insulin plus other high-cost drugs (e.g., Eliquis, Enbrel), insulin payments accelerate accumulation toward the cap. Once the beneficiary hits $2,000 OOP, all covered drugs (including insulin) cost $0 for the rest of the year.

Interaction with the Medicare Prescription Payment Plan (IRA Section 11202)

The Medicare Prescription Payment Plan (M3P), effective January 2025 under IRA Section 11202, lets beneficiaries spread their Part D out-of-pocket costs across monthly installments. For insulin-only users, M3P provides minimal benefit because $35/month is already a manageable monthly amount.

For beneficiaries with insulin plus high-cost drugs (e.g., a Georgia retiree on Lantus + Humalog + Eliquis + Jardiance), M3P spreads the combined annual OOP across 12 months. The insulin portion of the combined OOP is fixed at $35/month per insulin under Section 11406; the rest spreads under M3P up to $2,000 total.

Interaction with the Medicare Drug Price Negotiation Program (IRA Section 11401)

Among the first 10 negotiated Part D drugs effective January 1, 2026, Fiasp and NovoLog (insulin aspart, by Novo Nordisk) were selected by the Medicare Drug Price Negotiation Program. The program sets a Maximum Fair Price (MFP) for selected drugs, which creates a second cost protection alongside the $35 cap.

For a Georgia beneficiary on Fiasp in 2026, the 25% coinsurance applied to the MFP may produce a lower effective cost than the $35 cap, in which case the MFP-driven amount binds. Contact your Part D plan or GeorgiaCares (1-866-552-4464) for the current cost-sharing amount for Fiasp/NovoLog.

For insulins not selected for negotiation (Lantus, Humalog, Levemir, others), the $35 cap remains the binding constraint.

Interaction with Low Income Subsidy (LIS Extra Help)

Beneficiaries qualifying for Low Income Subsidy (Extra Help) under Section 1860D-14 pay reduced copayments well below $35. For LIS recipients, the LIS copayment is lower than $35, so the LIS amount binds. A Georgia LIS recipient on Lantus pays far less than $35.

LIS recipients also receive zero deductible and zero cost-sharing in catastrophic phase. The $35 cap acts as a backstop for LIS but is rarely binding.

Historical context: the road to the $35 cap

The $35 insulin cap did not arrive in a vacuum. It emerged from years of advocacy, research, and incremental policy efforts.

Pre-IRA insulin pricing

Before 2023, Medicare beneficiaries faced significant insulin costs. Average monthly prices at retail Georgia pharmacies in 2021-2022:

• Lantus: $300 to $400/month
• Toujeo: $400 to $500/month
• Humalog: $250 to $400/month
• Novolog/Fiasp: $250 to $450/month
• Tresiba: $400 to $600/month

At a typical 25% Part D Tier 3 coinsurance, beneficiaries paid $75 to $150/month per insulin. With deductibles and coverage gap mechanics, annual insulin out-of-pocket could exceed $3,000.

Insulin rationing reports

Federal data and advocacy organizations including the American Diabetes Association and JDRF documented insulin rationing. Approximately 25% of insulin users surveyed reported skipping doses, stretching pens, or splitting vials due to cost. For Medicare beneficiaries on fixed retirement income, this was particularly acute.

2021-2022 legislative efforts

Multiple bipartisan proposals emerged in 2021-2022. The Affordable Insulin Now Act (HR 6833, Reed, 2022) proposed a $35 cap on Medicare and ACA Marketplace insulin. The Insulin Affordability Act and similar proposals had bipartisan support but did not pass standalone.

IRA 2022 incorporation

The Inflation Reduction Act of 2022, signed by President Biden on August 16, 2022, absorbed the insulin cap as Section 11406. The cap was one of several Part D reforms in the IRA's prescription drug provisions, alongside the $2,000 OOP cap, M3P, and Drug Price Negotiation.

Implementation timeline

• January 1, 2023: Part D insulin cap effective under Section 1860D-2(b)(8)
• July 1, 2023: Part B insulin pump cap effective under Section 1833(t)(15)
• 2024-2025: CMS issued Final Rule (88 Fed Reg 78884, November 2023) clarifying implementation
• January 1, 2026: Drug Price Negotiation MFP for Fiasp/NovoLog took effect, dropping below $35 cap

Six worked examples: Georgia insulin users and the $35 cap

Worked example 1: Margaret 65 Atlanta Lantus

Margaret, 65, an Atlanta retiree, was diagnosed with Type 2 diabetes in 2022 and prescribed Lantus (long-acting insulin) at 1 vial per month.

Margaret's Lantus cost over time:

• Pre-2023: Plan placed Lantus on Tier 3 (brand) at 25% coinsurance
  • List price approximately $312/month
  • Margaret's OOP: $312 × 0.25 = $78/month, plus $480 deductible at start of year
  • Annual OOP for Lantus alone in 2022: $480 (deductible) + ($78 × 11 months) = $1,338
• January 2023: $35 cap effective with deductible waiver
  • Margaret's OOP: $35/month, $35 × 12 = $420/year
• 2024-2025: $35 cap continues
  • Margaret's OOP: $420/year
• 2026: $35 cap continues (Lantus not selected for negotiation)
  • Margaret's OOP: $420/year
• Annual savings vs 2022: $1,338 - $420 = $918/year

Worked example 2: Robert 70 Savannah Humalog + Lantus

Robert, 70, a Savannah retiree, has Type 1 diabetes and uses both rapid-acting (Humalog) and long-acting (Lantus) insulins.

Robert's combined insulin cost over time:

• Pre-2023: Both on Tier 3 at 25% coinsurance
  • Humalog $280 list × 0.25 = $70/month
  • Lantus $312 list × 0.25 = $78/month
  • Combined: $148/month plus deductible at start of year
  • Annual OOP for insulin in 2022: ~$1,776 + $480 deductible = $2,256
• January 2023: Both subject to $35 cap (separate per insulin)
  • Humalog: $35/month
  • Lantus: $35/month
  • Combined: $70/month, $840/year
• Annual savings vs 2022: $2,256 - $840 = $1,416/year

Worked example 3: Linda 67 Macon Fiasp pen

Linda, 67, a Macon retiree, uses Fiasp FlexTouch pens for Type 1 diabetes with intensive insulin management.

Linda's Fiasp cost over time:

• Pre-2023: Tier 3 brand coinsurance, plus deductible, varied by plan
• 2023-2025: $35/month under the insulin cap
• 2026: Fiasp selected for Medicare Drug Price Negotiation; the MFP-driven coinsurance may be lower than $35 — contact the plan or GeorgiaCares for the current amount
• Annual savings vs pre-2023: significant; $35/month or potentially less in 2026

Worked example 4: Charles 73 Augusta insulin pump (Part B)

Charles, 73, an Augusta retiree, has Type 1 diabetes and uses a Medtronic insulin pump (Part B DME).

Charles's insulin pump insulin cost over time:

• Pre-July 2023: 20% Part B coinsurance on negotiated rate, typically $200 to $300/month
  • Plus annual Part B deductible ($283 in 2026)
• July 2023+: $35/month under Section 1833(t)(15) with deductible waiver
  • Annual OOP for pump insulin: $420/year
• Annual savings vs pre-July-2023: substantial; $200 to $250/month previously, now $35

Worked example 5: Patricia 65 Columbus LIS recipient

Patricia, 65, a Columbus retiree, has Type 2 diabetes and qualifies for Low Income Subsidy (LIS Extra Help) with income at 130% of FPL.

Patricia's Lantus cost over time:

• Pre-IRA: LIS recipient paid reduced copayments on insulin
• Post-IRA: LIS recipient pays reduced copayments well below $35 (2026 amounts)
• 2023-2026 effective Lantus cost: LIS copayment, well below $35 (binding constraint)

For Patricia, the $35 cap is not binding because LIS already provides lower cost-sharing. The cap is a backstop but rarely triggered for LIS recipients.

Worked example 6: Henry 75 Athens travel out-of-network

Henry, 75, an Athens retiree, spends winter (January through March) in Florida visiting family. He runs out of Lantus while in Florida and fills the prescription at an out-of-network Florida pharmacy.

Henry's out-of-network fill:

• In-network Georgia fill: $35 under cap
• Out-of-network Florida fill: full retail $312 (or whatever the Florida pharmacy charges)
• Plan does not pay; cap does not apply
• Henry pays full cost
• Lesson: Use mail-order pharmacy for travel periods, or transfer prescription to a Florida pharmacy that is in your plan's national network.

Henry should contact his Part D plan before travel to identify in-network pharmacies at his destination. Most major chains (CVS, Walgreens, Walmart) are nationally networked across plans.

Plan formularies and the cap: what to verify during AEP

The $35 cap applies to insulin on the plan formulary. Georgia beneficiaries comparing plans during the Annual Enrollment Period (October 15 to December 7) should verify:

Formulary coverage of their specific insulin

Different plans cover different insulin products. A plan that covers Lantus may not cover Toujeo, or may require step therapy. Use Medicare Plan Finder at medicare.gov or GeorgiaCares (1-866-552-4464) for help comparing.

Pharmacy network

Confirm the local Georgia pharmacy you use is in the plan's preferred or standard network. The $35 cap applies at any in-network pharmacy but not out-of-network. Pharmacies in Georgia rural areas may not be in every plan's network.

Mail-order options

Plans typically partner with one mail-order pharmacy (CVS Caremark Mail Service, Express Scripts Home Delivery, OptumRx Mail Service, others). Mail-order can be convenient for 90-day fills of insulin, with the cap at $105 for 90-day supply.

Coverage exceptions

If your specific insulin is not on the plan formulary, request a coverage exception under Section 1860D-4(g). Your physician must support the request with medical justification. The plan has 72 hours to decide.

15 common mistakes Georgia beneficiaries make about the $35 insulin cap

1. Thinking the cap applies to all insulin at any pharmacy. It only applies to in-network Part D covered insulin (or Part B pump insulin).

2. Believing the deductible must be satisfied first. The deductible is waived for insulin under Section 1860D-2(b)(2)(D). $35 from January 1.

3. Not understanding the cap is per insulin, not per prescription. Two different insulin products mean two $35 caps. A beneficiary on Lantus + Humalog pays $70/month total ($35 each).

4. Confusing the cap with insulin list price reduction. The drug still has a list price; the cap limits beneficiary out-of-pocket only.

5. Believing the cap reduces what Medicare pays. The cap shifts cost from beneficiary to plan/Medicare. Total drug cost may be unchanged.

6. Not realizing the cap counts toward the $2,000 OOP cap. $35/month × 12 = $420/year contributes toward the cap.

7. Missing the Part B insulin pump cap. Section 1833(t)(15) is a separate statutory provision; pump users have the same $35 cap.

8. Believing the cap applies at out-of-network pharmacies. It does not. Use in-network pharmacies.

9. Confusing the cap with manufacturer patient assistance programs. The Lilly Insulin Value Program also caps at $35, but it is a separate manufacturer program. The IRA cap is statutory and universal across Medicare.

10. Not understanding LIS recipients already pay less. LIS (Extra Help) copayments are well below $35; the cap rarely binds for LIS recipients.

11. Believing the cap applies to over-the-counter retail. Walmart ReliOn and other OTC insulin purchased outside Medicare benefit are not subject to the cap.

12. Missing biosimilar coverage. Semglee (Lantus biosimilar) and Basaglar are covered.

13. Confusing the cap with the $35 Part B drug copayment for some drugs. Different provisions, different drugs.

14. Thinking the cap is permanent without legislative risk. The cap is statutory under IRA 2022. Congressional action would be required to repeal or modify it.

15. Not realizing the cap requires the insulin to be "covered." Must be on plan formulary or obtain coverage exception.

Quick reference: Georgia Medicare $35 insulin cap framework

What is the $35 Medicare insulin cap?

The $35 Medicare insulin cap limits beneficiary out-of-pocket cost-sharing on covered insulin to no more than $35 per 30-day supply (or $70 for 60-day, $105 for 90-day). The cap was created by Inflation Reduction Act 2022 Section 11406, took effect January 1, 2023, for Part D and July 1, 2023, for Part B insulin pumps.

Does the cap apply to all insulin?

The cap applies to covered insulin on the plan formulary, at in-network pharmacies, for Medicare beneficiaries enrolled in Part D (or Part B for insulin pumps). It applies to all long-acting, rapid-acting, intermediate, concentrated, and mixed insulins, both vial and pen formulations, branded and biosimilar.

Do I have to satisfy the Part D deductible first?

No. The Inflation Reduction Act waived the Part D annual deductible for covered insulin under Section 1860D-2(b)(2)(D). You pay $35 from January 1, not $590 + $35.

What if I take two insulins?

The cap applies per insulin product. If you take both Lantus (long-acting) and Humalog (rapid-acting), each is capped at $35, so your total monthly insulin cost is $70.

Does the cap apply to insulin pumps?

Yes. Part B insulin pump insulin is capped under Section 1833(t)(15) of the Social Security Act, effective July 1, 2023. The cap is $35 per 30-day supply with the Part B deductible waived under Section 1833(b)(11).

Can I use mail-order to get insulin at $35?

Yes. Mail-order pharmacies in your plan's network are subject to the same cap. A 90-day mail-order fill is capped at $105.

What happens if I fill insulin out-of-network?

The cap applies only to in-network pharmacy fills. Out-of-network insulin fills are generally not covered by your plan and the $35 cap does not apply. You would pay the full retail cost.

Does the cap apply at over-the-counter retail like Walmart ReliOn?

No. Walmart ReliOn is sold over-the-counter without a prescription claim. If you buy ReliOn or other OTC insulin without using your Medicare benefit, you pay retail (which may still be cheaper than $35 for some basic insulins).

How does the cap interact with the $2,000 OOP cap?

Insulin payments count toward the $2,000 annual out-of-pocket cap under IRA Section 11201. A beneficiary paying $35/month contributes $420/year. Once total Part D OOP reaches $2,000, all covered drugs (including insulin) cost $0 for the rest of the year.

How does the cap interact with Low Income Subsidy?

LIS recipients pay reduced copayments well below $35 in 2026. For LIS recipients, the LIS copayment binds; the $35 cap is a backstop but rarely triggered.

How does the cap interact with the Medicare Drug Price Negotiation Program?

For Fiasp/NovoLog (selected for 2026 negotiation), the Maximum Fair Price (MFP) set by the Medicare Drug Price Negotiation Program produces 25% coinsurance that may bind below the $35 cap. Contact your plan or GeorgiaCares (1-866-552-4464) for the current cost-sharing amount. For other insulins not selected for negotiation, the $35 cap remains the binding constraint.

Will the cap apply to other diabetes medications?

No. The cap is specific to insulin. Other diabetes medications (Jardiance, Januvia, Farxiga, Ozempic, Mounjaro, etc.) have separate cost-sharing rules. Some are subject to Medicare Drug Price Negotiation; others remain at standard plan cost-sharing.

Does the cap apply to Medicare Advantage Prescription Drug plans?

Yes. The cap applies to both standalone Part D plans (PDPs) and Medicare Advantage Prescription Drug plans (MA-PDs). Coverage scope and formulary placement may differ by plan.

Will the cap change in 2027 or later?

The cap is set at $35 by statute (IRA Section 11406). Changes would require Congressional action. The cap has been in effect since 2023; no legislative changes to the cap amount are currently pending.

What if my insulin isn't on the plan formulary?

Request a coverage exception under Section 1860D-4(g) and 42 CFR 423.578. Your physician must support the request with medical justification. If approved, the cap applies. If denied, you can appeal through the Part D appeals process.

What is the deductible waiver for insulin?

Section 1860D-2(b)(2)(D) of the Social Security Act waives the Part D annual deductible for covered insulin. In 2026, the deductible is $590 for most Part D claims; insulin is exempt from the deductible.

Are biosimilar insulins covered?

Yes. Semglee (biosimilar of Lantus, by Mylan/Biocon) and Basaglar (biosimilar of Lantus, by Lilly) are covered when on the plan formulary, with the $35 cap applying.

Does the cap apply to insulin under commercial insurance or Medicaid?

No. The federal cap applies only to Medicare. Commercial insurance and Medicaid have their own insulin coverage rules. Some states have implemented commercial insulin caps similar to Medicare's $35 cap.

How does the cap interact with M3P (Medicare Prescription Payment Plan)?

The cap and M3P operate independently. M3P spreads OOP costs across monthly installments. For insulin-only users, M3P provides minimal additional benefit because $35/month is already manageable. For multi-drug users, M3P spreads the combined annual OOP including insulin.

Can pharmacies offer additional discounts below $35?

The cap is a maximum, not a minimum. Some plans offer Tier 1 generic placement for certain insulins (Semglee, others) at copayments below $35. Pharmacy discount programs (manufacturer Insulin Value Programs) may also reduce cost below $35 for specific manufacturers.

What is the Lilly Insulin Value Program?

The Lilly Insulin Value Program is a manufacturer program separate from Medicare that caps Lilly insulins at $35/month for eligible patients. It applies to commercial and uninsured patients, not Medicare beneficiaries directly. Medicare beneficiaries should use the IRA Section 11406 cap, not the Lilly program.

What documentation do I need to verify the cap is being applied?

Your pharmacy receipt should show $35 or less per 30-day fill. If charged more, contact your Part D plan immediately. If unresolved, file a grievance with the plan, then escalate to Medicare (1-800-MEDICARE) or GeorgiaCares (1-866-552-4464).

How do I find free Georgia counseling on Medicare insulin coverage?

GeorgiaCares is Georgia's State Health Insurance Assistance Program (SHIP) providing free one-on-one counseling on Medicare. Call 1-866-552-4464. Counselors help compare plans, evaluate insulin coverage, apply for LIS Extra Help, and resolve plan disputes about the cap.

What if I need help affording insulin outside Medicare?

The American Diabetes Association (1-800-DIABETES) and JDRF (1-800-533-CURE) provide support and advocacy. Manufacturer patient assistance programs (Lilly Insulin Value Program 1-833-808-1234; Novo Nordisk Diabetes Patient Assistance 1-866-310-7549; Sanofi Insulin Valyou Savings 1-833-235-1565) provide additional assistance for eligible patients. :::

::: cta Georgia Medicare Insulin Cap Resources

Free help understanding the Medicare $35 insulin cap, the Inflation Reduction Act Section 11406 framework, and your Part D and Part B insulin options is available from these Georgia and federal organizations.

• GeorgiaCares (Georgia SHIP): 1-866-552-4464 : free one-on-one Part D counseling on insulin coverage
• Medicare: 1-800-MEDICARE (1-800-633-4227) : Part D enrollment, cap questions
• Social Security Administration: 1-800-772-1213 : Low Income Subsidy applications
• Georgia Department of Community Health Medicaid Member Services: 1-866-211-0950 : LIS coordination for dual eligibles
• American Diabetes Association: 1-800-DIABETES (1-800-342-2383) : diabetes advocacy
• JDRF: 1-800-533-CURE : Type 1 diabetes support
• Lilly Insulin Value Program: 1-833-808-1234 : manufacturer insulin assistance (non-Medicare)
• Novo Nordisk Diabetes Patient Assistance: 1-866-310-7549 : manufacturer assistance
• Sanofi Insulin Valyou Savings: 1-833-235-1565 : Sanofi manufacturer assistance
• AARP Georgia: 1-866-295-7283 : senior advocacy
• Medicare Rights Center: 1-800-333-4114 : national helpline for Medicare appeals
• Center for Medicare Advocacy: 1-860-456-7790 : legal assistance for Medicare disputes
• Justice in Aging: 202-289-6976 : national legal advocacy for low-income seniors
• Medicare Beneficiary Ombudsman: assistance with unresolved Medicare complaints
• 211 Georgia: dial 211 : referrals to local senior assistance
• Eldercare Locator: 1-800-677-1116 : connects to local Georgia Area Agencies on Aging
• Palmetto GBA Georgia MAC: 1-855-696-0705 : Georgia Medicare Administrative Contractor
• Brevy: brevy.com : comprehensive eldercare guides including Part D, the $35 insulin cap, the $2,000 OOP cap, and the Medicare Drug Price Negotiation Program for Georgia families :::

Disclaimer: This guide is for informational purposes only and does not constitute legal, financial, medical, or insurance advice. Medicare Part D rules, the $35 insulin cap, the $2,000 out-of-pocket cap, Low Income Subsidy thresholds, and plan-specific formularies change annually. Federal authorities cited include Section 11406 of the Inflation Reduction Act 2022 (Public Law 117-169), Section 1860D-2(b)(8) and Section 1833(t)(15) of the Social Security Act, 42 CFR 423.104(d)(2), 42 CFR 410.29, and CMS guidance current as of May 2026. For your specific situation, contact GeorgiaCares (1-866-552-4464) for free counseling or Medicare (1-800-MEDICARE) directly.