Impacted: Medicare Part D clients

What you need to know  

The Centers for Medicare and Medicaid Services (CMS) recently made changes to the Maximum Fair Price (MFP) for insulin as part of the Inflation Reduction Act (IRA). Beginning in 2026, the highest price Medicare members can pay for insulin products will be the lowest of these options:  
•    $35 total copayment 
•    25% of the MFP  
•    25% of the negotiated price of the covered insulin product under the Prescription Drug Plan (PDP) or the Medicare Advantage Prescription Drug Plan (MA-PDP) 

What this means for Prime clients 

If an insulin product is not on the MFP list  
Members must pay no more than $35 or 25% of the negotiated price, whichever is less. This does not prevent a plan from choosing a lesser amount for their copay/or coinsurance. Clients can set up an insulin copay of anything lower than $35 or any coinsurance cost of less than 25% of the MFP.
 
Clients can also set the pricing to follow the guidance of a conventional 25% of the negotiated price or $35, whichever is less. The adjudication system will make a pricing comparison to find the price with no additional pricing factors.  

If an insulin product is on the MFP list  
Members must pay no more than $35, 25% of the negotiated price or 25% of the MFP, whichever is less. This pricing requirement also does not prevent a plan from choosing a lesser amount for their copay/or coinsurance. The plan can set up an insulin copay of anything lower than $35 or coinsurance cost of less than 25% of the negotiated price and 25% of the MFP.
 
Alternatively, clients can set up the pricing to follow the conventional pricing guidance of $35, 25% of the negotiated price, or 25% of the MFP, with no additional pricing factors. The adjudication system will make a pricing comparison to find the final best price with no additional pricing factors. 

Currently, the 2026 MFP list only includes one insulin drug apart from Medicare price negotiations (Novolog / Fiasp). We anticipate that will change in coming years as more drugs are added due to the Inflation Reduction Act (IRA).  

The MFP for a 30-day supply of Novolog is 25% of MFP ($119) = $29.75. Today, the MFP price will be adjudicated at this price rather than the $35 cap. 

Next steps 

This message is for your awareness only. There are no actions required by clients at this time.

Questions

Reach out to your Prime client account team representative.