summary
Introduced
01/08/2025
01/08/2025
In Committee
01/08/2025
01/08/2025
Crossed Over
Passed
Dead
04/24/2025
04/24/2025
Introduced Session
2025 Regular Session
Bill Summary
Restriction on co-pay accumulators. Provides that under certain circumstances, the administrator of a state employee health plan shall include any amount paid by a covered individual or another person on behalf of the covered individual for a prescription drug when calculating a covered individual's overall contribution to an out-of-pocket maximum or cost sharing requirement under the covered individual's state employee health plan. Provides that under certain circumstances, a pharmacy benefit manager shall include any amount paid by a covered individual or another person on behalf of the covered individual for a prescription drug when calculating a covered individual's overall contribution to an out-of-pocket maximum or cost sharing requirement under the covered individual's health plan. Provides that under certain circumstances, an insurer that issues a policy of accident and sickness insurance shall include any amount paid by an insured or another person on behalf of the insured for a prescription drug when calculating an insured's overall contribution to an out-of-pocket maximum or cost sharing requirement under the insured's policy of accident and sickness insurance. Provides that under certain circumstances, a health maintenance organization shall include any amount paid by an enrollee or another person on behalf of the enrollee for a prescription drug when calculating an enrollee's overall contribution to an out-of-pocket maximum or cost sharing requirement under the enrollee's individual or group contract.
AI Summary
This bill addresses co-pay accumulators by requiring various health insurance entities in Indiana to include manufacturer copay assistance and other third-party payments when calculating an individual's out-of-pocket expenses, effective July 1, 2025. Specifically, the bill applies to state employee health plans, pharmacy benefit managers, accident and sickness insurance policies, and health maintenance organization (HMO) contracts. The legislation includes important exceptions for brand-name drugs with available generic alternatives, but only when the patient cannot access the brand-name drug through prior authorization, step therapy, or exceptions/appeals processes. Key definitions are provided, such as what constitutes a "generic alternative" (a therapeutically equivalent drug designated by the FDA and nationally available) and clarifying terms like "covered individual" and "insured". The primary goal is to prevent insurance providers from excluding manufacturer copay assistance from counting toward a patient's out-of-pocket maximum, which could potentially make prescription medications more affordable for individuals by ensuring all payments contribute to their annual cost-sharing requirements.
Committee Categories
Health and Social Services
Sponsors (1)
Last Action
First reading: referred to Committee on Health and Provider Services (on 01/08/2025)
Official Document
bill text
bill summary
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bill summary
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bill summary
| Document Type | Source Location |
|---|---|
| State Bill Page | https://iga.in.gov/legislative/2025/bills/senate/133/details |
| BillText | https://iga.in.gov/pdf-documents/124/2025/senate/bills/SB0133/SB0133.01.INTR.pdf |
| Fiscal Note #1: Introduced | https://iga.in.gov/pdf-documents/124/2025/senate/bills/SB0133/fiscal-notes/SB0133.01.INTR.FN001.pdf |
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