There’s no single “best” health insurance plan for everyone with diabetes, but the best plan for you will have three things: low out-of-pocket costs for insulin and other diabetes medications, coverage for devices like continuous glucose monitors, and strong benefits for the ongoing lab work and specialist visits diabetes requires. Your best option depends on whether you’re shopping on the ACA Marketplace, choosing through an employer, or eligible for Medicare.
What Makes a Plan Good for Diabetes
Diabetes is expensive to manage. Between insulin, oral medications, test strips, continuous glucose monitors, and regular A1C blood tests, costs add up fast. The right plan minimizes what you pay for these recurring needs. When comparing plans, look beyond the monthly premium and focus on these factors:
- Formulary tier for your medications. Every plan sorts covered drugs into cost tiers. Insulin on a lower tier means a lower copay. Newer medications for blood sugar control and weight management often land on higher, more expensive tiers. Before enrolling, check the plan’s prescription drug list to see exactly where your medications fall.
- Annual out-of-pocket maximum. This is the most you’ll spend in a year before the plan covers everything at 100%. For a condition that generates steady costs all year, a lower out-of-pocket max can save you thousands.
- Specialist and lab visit costs. Diabetes typically means visits to an endocrinologist, an ophthalmologist, and sometimes a podiatrist or dietitian. Plans that require high copays for specialists or charge coinsurance for lab work will cost you more over time.
- Device coverage. If you use or want a continuous glucose monitor or insulin pump, check whether the plan covers these under its durable medical equipment benefit and what prior authorization hoops are required.
The Federal $35 Insulin Cap
The Inflation Reduction Act capped out-of-pocket insulin costs at $35 per month for Medicare beneficiaries starting in 2023. This applies to both Part B (insulin used with a traditional pump) and Part D (injectable insulin and insulin used with disposable pumps). The Part B deductible doesn’t apply to insulin, so you pay $35 or less per monthly supply with no deductible to meet first.
For people with private insurance, the picture is different. Many major insurers have voluntarily adopted $35 insulin copay programs, and more than 20 states have enacted their own insulin cost-sharing caps. If you’re shopping on the Marketplace or through an employer, check whether your state has a cap in place and whether the plan you’re considering participates in a $35 insulin program.
Medicare Coverage for Diabetes
Medicare is one of the more comprehensive options for diabetes management, especially after recent legislative changes. Part B covers insulin pumps worn outside the body, the insulin used with those pumps, blood sugar testing supplies, and therapeutic shoes for people with diabetic nerve damage. Part D covers injectable insulin not used with a traditional pump.
Continuous glucose monitors are covered under Medicare if you take insulin or have a history of low blood sugar episodes. Your doctor needs to evaluate your condition and confirm that you or your caregiver have been trained to use the device properly. Once approved, Medicare covers the monitor and its related supplies.
Medicare also covers diabetes self-management training, medical nutrition therapy, and screenings for diabetic eye disease and kidney problems. If you’re choosing between Medicare Advantage plans, look for ones rated 4.5 or 5 stars by the National Committee for Quality Assurance (NCQA), which evaluates plans on clinical quality and patient experience. In 2025, top-rated plans include those from Kaiser Foundation, Blue Cross Blue Shield of Massachusetts, Independent Health Association, and several UPMC plans.
ACA Marketplace Plans
All ACA Marketplace plans must cover certain diabetes-related preventive services at zero cost to you, with no copay or coinsurance. These include Type 2 diabetes screening for adults aged 40 to 70 who are overweight or obese, diet counseling for people at higher risk for chronic disease, and obesity screening and counseling. These services are fully covered regardless of whether you’ve met your deductible.
Beyond preventive care, Marketplace plans vary widely in how they handle diabetes costs. Silver plans are often the sweet spot for people with diabetes because they qualify for cost-sharing reductions if your income is below 250% of the federal poverty level. These reductions lower your deductible, copays, and out-of-pocket maximum, which makes a significant difference when you’re filling prescriptions and seeing specialists every few months.
Gold and Platinum plans have higher premiums but lower cost-sharing, which can be worth it if you know you’ll hit your deductible early in the year anyway. Bronze plans with their low premiums and high deductibles are generally a poor fit for diabetes, since you’ll pay full price for medications and visits until you reach a deductible that can exceed $7,000.
High Deductible Plans and HSAs
High deductible health plans (HDHPs) paired with health savings accounts (HSAs) might seem like a bad match for diabetes, since you normally pay full price for everything until you hit a high deductible. But an important IRS rule changes the math for insulin users. Since 2023, HDHPs can cover insulin products before you meet your deductible without disqualifying you from contributing to an HSA. This applies to all insulin products, whether prescribed for managing diabetes or preventing complications, and it includes the devices used to deliver the insulin.
The HSA itself is a powerful tool for managing diabetes costs. Contributions are tax-deductible, the money grows tax-free, and withdrawals for medical expenses are untaxed. If you can afford to fund an HSA while covering your ongoing costs, the triple tax advantage adds up over years of chronic disease management. This approach works best for people who have enough income to contribute meaningfully to the HSA and enough savings to absorb costs that aren’t covered before the deductible.
HDHPs also cover the same ACA-mandated preventive services at no cost, including diabetes screenings. And many HDHPs now cover additional preventive care for chronic conditions, like certain blood pressure and cholesterol medications, before the deductible.
Employer Plans: What to Compare
If you’re choosing between plans during open enrollment at work, the formulary is your most important document. Large insurers like UnitedHealthcare organize their drug lists into three to five tiers, and some offer preferred insulins at no out-of-pocket cost on their lowest tier. The difference between a plan that puts your insulin on Tier 1 and one that puts it on Tier 3 can be hundreds of dollars per month.
Ask your benefits department whether any offered plans include a diabetes management program. Many large employers now offer plans with built-in chronic disease support: free coaching, discounted or covered continuous glucose monitors, and reduced copays for diabetes medications. These programs aren’t always obvious from the plan summary alone.
If your employer offers both a PPO and an HMO, the HMO will typically have lower out-of-pocket costs but require referrals to see specialists. For diabetes, where you need regular access to an endocrinologist and possibly other specialists, a PPO’s flexibility can be worth the higher premium. Run the numbers both ways: add up the premium difference over 12 months and compare it to the copay savings you’d get from the lower-cost plan.
Checking a Plan’s Drug List Before You Enroll
Every insurer publishes its formulary, usually as a searchable tool or downloadable PDF on its website. Before committing to any plan, look up every medication you take. Note the tier, whether prior authorization is required, and whether there are quantity limits. A plan that looks affordable on paper can become expensive if it requires you to try a cheaper medication first (called step therapy) before it will cover the one your doctor prescribed.
Pay special attention to newer diabetes medications that help with blood sugar control and have cardiovascular or kidney-protective benefits. These tend to sit on higher formulary tiers with significant coinsurance, sometimes 30% to 50% of the drug’s cost. If you take one of these medications, a plan with a lower out-of-pocket maximum may save you more than one with lower copays on other drugs.
Formularies can change at the start of each plan year. A medication covered this year could move to a higher tier or be removed entirely next year. Check the formulary during every open enrollment period, not just the year you first sign up.