Sponsors (10)
The bill limits annual out-of-pocket prescription spending for patients—reducing financial strain and disparities—but may shift costs across the system (higher premiums, stricter management, and administrative burdens) and leaves long-term generosity exposed to medical inflation.
People with chronic conditions and others who face high prescription costs will have an annual out-of-pocket cap ($2,000 individual / $4,000 family starting 2026), sharply limiting their maximum drug spending.
Families that face high medication bills (including middle-class and low-income households) will get predictable maximum yearly drug spending, improving financial planning and reducing the risk of medical debt.
People covered by individual and group health plans will face the same drug cost limits across markets (ACA, ERISA, PHS Act, and IRC), reducing disparities in drug cost exposure between different plan types.
Insured Americans, employers, and taxpayers may face higher premiums, narrower drug formularies, or increased non-drug cost-sharing as insurers and employers shift costs to offset capped drug spending.
Patients with chronic conditions may encounter more restrictive utilization management (prior authorization, step therapy), which can delay or complicate timely access to some medications.
Employers and health insurance issuers will face increased federal compliance and administrative costs to implement and administer the new caps.
Based on analysis of 2 sections of legislative text.
Limits annual prescription drug out-of-pocket costs to $2,000 per individual and $4,000 per family for plan years starting in 2026, with annual CPI‑U indexing thereafter.
Introduced April 1, 2025 by Steven Horsford · Last progress April 1, 2025
Caps annual out-of-pocket prescription drug cost-sharing for insured people and families: $2,000 per individual and $4,000 per family for plan years beginning in 2026, with those caps indexed to the medical care component of the CPI‑U in later years. The rule is applied across the individual market and the group market by amending major health plan laws so group health plans and issuers must follow the same limits. All changes take effect for plan years beginning on or after January 1, 2026.