This bill would amend the Public Health Service Act, ERISA, and the Internal Revenue Code. It requires group health plans and health insurance issuers (group and individual coverage) to count any out-of-pocket money an individual spends to buy a drug toward that person's deductible and out-of-pocket maximum if the individual buys the drug without using plan benefits. The bill also makes conforming changes to Medicaid pricing rules (best price and average manufacturer price) to exclude price reductions when an individual purchases a drug without applying plan benefits. The changes apply to plan years beginning on or after January 1, 2027.
If your plan covers a drug but you choose to pay for it without using your plan benefits, the money you spend must be counted toward your deductible and your out-of-pocket maximum that would have applied if you had used benefits. This applies to people in group plans and people with individual coverage.
No publicly available information on the bill's estimated fiscal cost, effects on premiums, or costs to insurers appears in the bill text or provided metadata.
The bill's sponsors would require that out-of-pocket purchases of covered drugs count toward deductibles and out-of-pocket maximums so those payments are credited to an enrollee's benefit limits. Sponsors named in the bill metadata include Representatives Gregory Murphy, Blake Moore, Tom Barrett, Chuck Edwards, Claudia Tenney, August Pfluger, Mike Flood, and Pat Harrigan.
No publicly available information on opponents' views or formal objections appears in the bill text or provided metadata.