Sponsors (14)
This bill reduces and stabilizes out-of-pocket prescription costs for many patients (including those in employer plans) while likely shifting costs and administrative burdens to insurers, employers, and taxpayers and leaving some access and pricing issues unresolved.
People who take prescription drugs (including those in employer-sponsored group plans) will face predictable lower annual out-of-pocket costs capped at $2,000 per person and $4,000 per family starting in 2026.
People who regularly use expensive medicines (especially those with chronic conditions) will likely experience fewer financial shocks and better medication adherence due to the predictable maximum cost-sharing.
The out-of-pocket caps will be adjusted annually to keep pace with medical inflation because amounts are indexed to the medical care CPI-U after 2026, helping preserve the cap's real value over time.
Insurers, employers, and taxpayers may face higher plan costs and administrative burdens that could be passed on as higher premiums, reduced wages, or increased public spending.
Some plans may respond to the cap by narrowing formularies, increasing prior authorization, or otherwise tightening utilization management, which could limit access to certain medicines for patients.
People without insurance and broader drug pricing (list prices) may see little or no direct relief from this law, so overall drug spending and affordability for the uninsured could remain unchanged.
Based on analysis of 2 sections of legislative text.
Caps annual out‑of‑pocket prescription drug cost‑sharing at $2,000 per person and $4,000 per family for private and marketplace plans, with annual CPI adjustments.
Introduced February 11, 2025 by Raphael Gamaliel Warnock · Last progress February 11, 2025
Sets a federal cap on how much people pay out of pocket for prescription drugs under private and marketplace health plans: $2,000 per person and $4,000 per family each year, starting for plan years that begin in 2026. The caps apply to qualified health plans sold on the ACA marketplaces and to group health plans and issuers (through matching changes to the Public Health Service Act, ERISA, and the Internal Revenue Code) and are adjusted annually for inflation.