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Requires group health plans and health insurance issuers to count amounts paid by or on behalf of an enrollee — including manufacturer coupons and nonprofit drug-assistance payments — toward the enrollee’s deductibles, copayments, coinsurance, and other cost-sharing. Adds a safe harbor in the tax code so that counting these third‑party payments for outpatient prescription drugs will not cause a high-deductible health plan (HDHP) to lose HDHP/HSA status. Applies to group health plans and issuers for plan years beginning on or after January 1, 2026. The measure explicitly includes specialty drugs and drugs subject to utilization management, while preserving prior authorization, step therapy, and other utilization-management tools.
The bill makes third‑party copay assistance count toward patient cost‑sharing — reducing immediate out‑of‑pocket drug costs and preserving HSA status for HDHP enrollees — at the potential cost of weakening long‑term price pressure on insurers/manufacturers and prompting plan responses (more utilization management or formulary changes) that could delay access and raise administrative burden.
People with high prescription drug costs (including specialty‑drug patients) who use manufacturer or nonprofit copay assistance will reach deductibles or out‑of‑pocket limits sooner, lowering their immediate out‑of‑pocket spending starting in plan years on/after Jan 1, 2026.
Health plans can continue using utilization management tools (like prior authorization and step therapy) while ensuring third‑party drug payments still count toward cost‑sharing, preserving care‑management practices without blocking the benefit of assistance payments.
Owners of high‑deductible health plans (HDHPs) — including many middle‑class families — keep HSA eligibility because the bill clarifies that counting third‑party drug assistance toward cost‑sharing does not violate HDHP safe‑harbor rules.
Taxpayers and the broader healthcare market could see less downward pressure on insurer and manufacturer list prices, because third‑party assistance counting toward cost‑sharing reduces incentives for payers or makers to lower list prices over time.
Patients (especially those with chronic conditions) may face increased delays or hurdles to access if plans respond by redesigning formularies or ramping up utilization management (e.g., stricter prior authorization or step therapy) to control pharmacy costs.
Health insurance issuers and plan sponsors will incur administrative and compliance costs to update systems and accounting so third‑party drug payments are properly tracked and counted toward cost‑sharing.
Introduced March 5, 2025 by Roger Wayne Marshall · Last progress March 5, 2025