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The bill lowers and standardizes patient out‑of‑pocket costs for in‑network outpatient drugs, but shifts cost pressure and administrative burdens onto plans, employers, and local markets, which could raise premiums, reduce benefits, or limit access in some areas.
People who fill in‑network outpatient prescriptions will pay no more in cost‑sharing than the HHS‑surveyed nationwide average price for that drug, lowering out‑of‑pocket costs for patients.
Health plans must contractually require PBMs to apply the same cost‑sharing cap, reducing PBM practices that shift higher copays onto patients.
Standardizing the cap to a nationwide average creates a predictable ceiling for patient cost sharing across plans that start the same plan year.
Insurers and employers may have to absorb the difference between negotiated prices and the nationwide average, raising plan costs which could lead to higher premiums or reduced benefits for individuals and employers.
Plans, PBMs, and other administrators will need new systems and processes to track HHS survey prices and ensure compliance, increasing administrative burden and implementation costs.
A nationwide average may not reflect local market prices, so plans could narrow provider networks or reduce participation in low‑price areas, harming access for some communities.
Based on analysis of 2 sections of legislative text.
Limits out‑of‑pocket cost sharing for covered outpatient drugs at in‑network pharmacies to the nationwide average consumer purchase price for each drug.
Representative · D-MI
Official title: To amend title XXVII of the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to ensure cost sharing for a drug does not exceed the nationwide average of consumer purchase prices for such drug.
Introduced August 20, 2026 by Hillary Scholten · Last progress August 20, 2026
This bill prohibits group health plans and health insurance issuers from charging patients more than the nationwide average consumer purchase price for covered outpatient prescription drugs dispensed at an in‑network pharmacy. Plans must also require any pharmacy benefit manager (PBM) they use to follow the same rule. The rule applies to plan years beginning on or after enactment and is implemented by adding matching provisions to the Public Health Service Act, ERISA, and the Internal Revenue Code so the requirement applies across employer plans, group market plans, and the tax code treatment of such plans.