CurrentWest Virginia Offices of the Insurance CommissionerPolicy 22-09

Cost Sharing in Prescription Insulin Drugs

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This bulletin provides West Virginia guidance on the statutory cost-sharing limit and coverage requirements for prescription insulin drugs. It directs health plans and insurers to limit a covered person's combined cost sharing for insulin to no more than $100 for a 30-day supply, regardless of the quantity or insulin categories used.

Policy Summary

PayerWest Virginia Offices of the Insurance Commissioner

PolicyCost Sharing in Prescription Insulin Drugs

Policy CodePolicy 22-09

Change TypeClarification

Effective DateNot specified

Next Review DateNot specified

Key ActionEnsure total point-of-sale cost sharing for covered prescription insulin does not exceed $100 for a 30-day supply.

SourceLink

POLICY UPDATE CHANGES

The $100 cost-sharing limit applies once to all combined insulin drug categories used to meet a covered person's needs during the same 30-day period, rather than separately to each insulin category.

$100Maximum combined cost sharing

30 daysSupply period

7Required insulin categories

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CurrentWest Virginia Offices of the Insurance CommissionerPolicy 22-09

Cost Sharing in Prescription Insulin Drugs

Customize your policy alerts

Sign up for West Virginia Offices of the Insurance Commissioner Policy 22-09 alerts

Get alerted when Policy 22-09 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWest Virginia Offices of the Insurance Commissioner

PolicyCost Sharing in Prescription Insulin Drugs

Policy CodePolicy 22-09

Change TypeClarification

Effective DateNot specified

Next Review DateNot specified

Key ActionEnsure total point-of-sale cost sharing for covered prescription insulin does not exceed $100 for a 30-day supply.

SourceLink

POLICY UPDATE CHANGES

The $100 cost-sharing limit applies once to all combined insulin drug categories used to meet a covered person's needs during the same 30-day period, rather than separately to each insulin category.

$100Maximum combined cost sharing

30 daysSupply period

7Required insulin categories

Prescription Insulin Coverage and Cost Sharing

Prescription Insulin Coverage and Cost-Sharing Requirements

For a covered person receiving covered prescription insulin, all of the following coverage and cost-sharing requirements apply:

ALL of the following

The health plan covers at least one type of insulin in each of these categories: rapid-acting, short-acting, intermediate-acting, long-acting, pre-mixed insulin products, pre-mixed insulin/GLP-1 RA products, and concentrated human regular insulin.
The covered person's total cost sharing for all covered prescription insulin used to meet the person's needs does not exceed $100 for a 30-day supply.
The $100 limit applies regardless of the quantity or number of insulin drug categories used during the same 30-day period.

Cost Sharing and Coverage Parameters

Maximum Cost Sharing

Maximum combined cost sharing$100 or less for all combined covered insulin categories during a 30-day period

Supply Period

Applicable supply period30-day supply

Required Insulin Category Coverage

Required coverageAt least one type of insulin in each of seven categories: rapid-acting, short-acting, intermediate-acting, long-acting, pre-mixed insulin products, pre-mixed insulin/GLP-1 RA products, and concentrated human regular insulin

Operational Requirements for Health Plans and Insurers

Billing Rule

Apply one combined insulin cost-sharing cap

Ensure that a covered person's total point-of-sale cost sharing for covered prescription insulin does not exceed $100 for a 30-day supply, regardless of the quantity or number of insulin categories used. The $100 limit applies once to all combined insulin drug categories within the same 30-day period.

Note

Maintain coverage across required insulin categories

Cover at least one type of insulin in each of the seven required categories.

Rapid-acting
Short-acting
Intermediate-acting
Long-acting
Pre-mixed insulin products

Applicable Terms

Cost-Sharing Payment

Cost-sharing paymentThe total amount a covered person is required to pay at the point of sale in order to receive a prescription drug covered under the covered person's health plan.

Covered Prescription Insulin

Covered prescription insulinA prescription insulin drug covered under the covered person's health plan and supplied for the covered person's prescription needs.