New Jersey locked in new cost-sharing rules for state-regulated insurers, finalising a set of caps lawmakers approved earlier and already in motion.
The Department of Banking and Insurance announced the completion of the regulations on Dec. 2, saying carriers must now adhere to strict limits on what consumers pay out of pocket for insulin, asthma inhalers and epinephrine auto-injectors.
Gov. Phil Murphy had signed the statute that made New Jersey the second state to impose caps on inhalers and EpiPens, extending an existing insulin cap to more markets.
The law pulls Medicare’s $35-a-month insulin limit into New Jersey’s fully insured market, its public employee plans and Get Covered New Jersey, the state’s health insurance marketplace.
It also pins EpiPen out-of-pocket costs at $25 and sets a $50 cap for asthma inhalers per monthly supply, no matter which device or formulation a doctor prescribes.
Commissioner Justin Zimmerman said the rules fit into a broader push to keep marketplace coverage affordable and nudged residents to shop plans during Open Enrollment.
Open Enrollment for 2026 coverage runs Nov. 1, 2025 through Jan. 31, 2026. Anyone who wants coverage starting Jan. 1 needs to enrol by Dec. 31; those who sign up by Jan. 31 start Feb. 1.
For insurers, P.L. 2023, Chapter 105 makes the caps binding as of Jan. 1, 2025. Fully insured carriers in the individual and small-employer markets must cover these medications without applying deductibles and can’t charge copays or coinsurance above the statutory thresholds.
Equipment and supplies for diabetes care and diabetes self-management education also fall within the required coverage.
Asthma inhaler limits apply across the board – $50 for any 30-day supply – and at least one epinephrine auto-injector must be available at $25.
That consistency matters for families managing chronic conditions and for carriers building formularies that now face tighter constraints on cost sharing.
The regulations also wire in obligations from P.L. 2023, Chapter 275, known as Grace’s law.
Insurers must cover hearing aids and cochlear implants, remove age caps, eliminate the old $1,000 coverage limit and fund one device per impaired ear every 24 months.
Out-of-pocket payments related to primary-care visits and hearing devices can’t be routed through durable medical equipment rules to inflate consumer costs.
The final package closing the loop on a set of reforms designed to shrink the everyday financial shock tied to essential medications and hearing-care devices.
