Out-of-Pocket Spending for Insulin by Medicare Beneficiaries After Monthly Caps

Importance: In Medicare, out-of-pocket spending for insulin was capped at $35 per month for some patients in 2021 and for all patients in 2023. However, independent evaluations of the federal cap and clinical outcomes are lacking. Objective: To measure changes in patient spending, insulin use, and health outcomes associated with the $35 monthly insulin out-of-pocket cap. Design, Setting, and Participants: This cohort study used an interrupted time-series analysis of data from Medicare Part D beneficiaries with type 2 diabetes (T2D) included in the IQVIA national longitudinal open claims database from 2019 to 2023; a subset of patients had linked data from ambulatory electronic medical records. The analysis was performed between January and July 2025. Exposures: Implementation of the $35 monthly insulin out-of-pocket cap to some beneficiaries in January 2021 and all beneficiaries in January 2023. Main Outcomes and Measures: Outcomes included mean quarterly insulin out-of-pocket spending, mean daily units of insulin, mean hemoglobin A1c level, and incidence rates of severe hypoglycemia resulting in hospitalizations or emergency department visits. Changes were assessed using segmented regression with generalized estimating equations, adjusted for patient age and sex and within-year seasonal variation. Results: The study included 4.8 million patients, with a median quarterly cohort size of 1 393 402 patients (range, 1 261 976-1 475 460). In the first quarter of 2019, the baseline cohort included 707 416 males (51.1%), with 711 075 patients (51.3%) aged 65 to 74 years. Mean quarterly insulin out-of-pocket spending was $192.66 (95% CI, $192.63-$192.68) at baseline and declined by $47.90 (95% CI, -$48.95 to -$46.84) in 2021 and by another $58.59 (95% CI, -$59.91 to -$57.27) in 2023. Among all patients with T2D, mean daily insulin use was 12.86 (95% CI, 12.86-12.87) units at baseline and increased by 0.23 (95% CI, 0.15-0.31) units in 2023. Among a subset of 207 197 patients with linked electronic medical record data, mean hemoglobin A1c level was 7.28% (95% CI, 7.28%-7.28%) at baseline and decreased by 0.06% (95% CI, -0.08% to -0.03%) after 2023. There were corresponding modest increases in rates of severe hypoglycemic events. Conclusions and Relevance: In this cohort study, a $35 monthly insulin out-of-pocket cap was found to be associated with significantly lower insulin out-of-pocket spending, increased access to insulin, and decreased blood glucose levels among Medicare beneficiaries with T2D. These findings suggest federal cost-sharing policies could improve access and adherence to essential medications in diabetes and other chronic diseases.