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The bill reduces out-of-pocket drug costs for individuals who pay cash or use coupons by requiring those payments to count toward deductibles/OOP limits, but it risks prompting manufacturer and insurer reactions (higher list prices, reduced discounts, or changed coverage) that could raise premiums or limit drug access for many Americans.
Patients (especially those with chronic conditions and uninsured individuals) will have cash payments and point-of-sale manufacturer coupon payments count toward their plan deductibles and out-of-pocket maximums, letting them reach their annual limits sooner and reducing their future cost-sharing.
Plan enrollees nationwide benefit from consistent rules because the bill aligns counting standards across the PHSA, ERISA, and the Internal Revenue Code, standardizing consumer protections beginning in 2027.
Insured Americans and taxpayers could face higher premiums or more restricted drug coverage if insurers and plans change formularies, rebate arrangements, or coverage policies to offset lost manufacturer discount dynamics.
Medicaid beneficiaries and other patients could be harmed if drug manufacturers respond to higher effective Medicaid best-price calculations by raising list prices or reducing discounts.
Patients who rely on point-of-sale coupons or manufacturer assistance may see reduced availability of those programs if manufacturers alter assistance strategies in response to the new counting rules.
Based on analysis of 2 sections of legislative text.
Requires health plans to count cash payments for prescription drugs toward an enrollee's deductible and out‑of‑pocket maximum and excludes such cash price reductions from Medicaid best price/AMP calculations.
Introduced April 14, 2026 by Gregory Francis Murphy · Last progress April 14, 2026
Requires group and individual health plans and issuers to count a patient’s full out‑of‑pocket cash payment for a prescription drug toward the deductible and out‑of‑pocket maximum that would have applied if the plan’s benefits had been used. Also changes Medicaid pricing rules so discounts tied to these cash purchases are excluded from manufacturers’ Medicaid "best price" and Average Manufacturer Price calculations. The counting requirement applies to plan years starting on or after January 1, 2027.