New Jersey Caps Prescription Drug Copays for State-Regulated Health Plans

TRENTON, NJ — New regulations adopted by the New Jersey Department of Banking and Insurance (DOBI) now officially cap out-of-pocket costs for insulin, asthma inhalers, and epinephrine auto-injectors in health insurance plans regulated by the state. The final rules, published in the New Jersey Register on December 1, 2025, implement provisions of a 2023 law aimed at reducing prescription drug costs for consumers across the state.

Beginning January 1, 2025, fully insured health plans—including those offered through the individual and small employer markets, as well as public employee plans and Get Covered New Jersey, the state’s official health insurance marketplace—are required to limit consumer cost-sharing for these essential medications. Under the law, insurers must provide these drugs without deductibles and must adhere to specific monthly caps:

• $35 for insulin, regardless of type or number of prescriptions;

• $50 for asthma inhalers per 30-day supply;

• $25 for epinephrine auto-injectors per 30-day supply.

The rules also mandate coverage for diabetes-related supplies and education and clarify that caps apply regardless of the formulation prescribed.

The new regulation stems from P.L. 2023, Chapter 105, signed into law to align state-regulated plans with recent federal cost-sharing limits enacted under Medicare for insulin. New Jersey was among the first states to expand this approach to include asthma and allergy medications, adding cost protection for patients managing chronic respiratory and allergic conditions.

In addition to prescription drug cost caps, the Department’s final rules also implement provisions of Grace’s Law (P.L. 2023, Chapter 275), expanding access to hearing health care. The updated rules:

• Remove the age limit and $1,000 cap on hearing aid coverage;

• Require insurers to cover one hearing aid per ear every 24 months, including cochlear implants;

• Clarify that hearing aids and cochlear implants must be treated similarly to other covered medical services, not as durable medical equipment, when calculating out-of-pocket costs.

Consumers' out-of-pocket costs for hearing-related care are now limited to the same level as a primary care provider visit, offering potentially significant financial relief to individuals with hearing impairments.

These changes affect only fully insured health plans regulated by the state, meaning self-funded plans, typically offered by larger employers, are not bound by these requirements unless they voluntarily adopt them.

Open Enrollment for 2026 health coverage through Get Covered New Jersey is currently underway and runs through January 31, 2026. Consumers must enroll by December 31, 2025, for coverage beginning January 1, 2026. Enrollments completed in January will take effect February 1, 2026.

The finalization of these rules follows prior guidance from the Department and collaboration with the Governor’s Office of Health Care Affordability and Transparency, continuing an ongoing effort to regulate health care costs and improve coverage for New Jersey residents.

Residents seeking more information on their coverage options or the new cost caps can visit the Department of Banking and Insurance at nj.gov/dobi or the Get Covered New Jersey website at nj.gov/getcoverednj.

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