Sponsors (8)
The bill improves affordability for patients who pay cash or use coupons and shields federal rebate calculations, but shifts costs onto insurers, employers, and possibly triggers manufacturer price responses that could raise drug prices more broadly.
Patients who pay cash or use manufacturer coupons will have those payments count toward their insurance deductibles and out-of-pocket maximums, reducing their future cost-sharing and improving affordability for people with high-cost chronic conditions.
Medicaid and other federal program spending may be protected from distortions to drug rebate calculations by excluding cash-purchase discounts from "best price"/AMP calculations, which could help stabilize federal program drug rebates and budgets.
Health plans and insurers may face higher cost exposure if more cash payments count toward plan limits, which could lead to higher premiums, reduced benefits, or cost-shifting onto enrollees and taxpayers over time.
Drug manufacturers could lose leverage to target patient assistance to specific benefit designs and may respond by raising list prices or changing discount strategies, which could increase drug costs for some patients.
Employers sponsoring group health plans could face higher plan costs if more cash payments count toward limits, potentially increasing employer premiums or required contributions and affecting small businesses in particular.
Based on analysis of 2 sections of legislative text.
Requires plans to count off‑plan drug purchases toward deductibles/out‑of‑pocket maximums and excludes those prices from Medicaid best price/AMP calculations.
Introduced April 14, 2026 by Gregory Francis Murphy · Last progress April 14, 2026
Requires group health plans and insurance issuers to count a patient’s out-of-pocket payment for a drug — when the patient chooses to buy the drug without using plan benefits — toward that plan’s deductible and out-of-pocket maximum. Also changes how drug manufacturers’ prices are calculated for Medicaid by excluding such off‑plan purchases from "best price" and "average manufacturer price" calculations. Changes apply to plan years beginning on or after January 1, 2027.