summary
Introduced
01/13/2025
01/13/2025
In Committee
01/13/2025
01/13/2025
Crossed Over
Passed
Dead
04/24/2025
04/24/2025
Introduced Session
2025 Regular Session
Bill Summary
Prohibition on copay accumulator adjustments. Provides that under certain circumstances, the administrator of the 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 who 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 prohibits copay accumulator adjustments across various health insurance contexts in Indiana, effective July 1, 2025. Specifically, the bill requires administrators of state employee health plans, pharmacy benefit managers, insurers, and health maintenance organizations to include any amount paid by a covered individual or on their behalf for a prescription drug when calculating the individual's overall contribution to out-of-pocket maximums or cost-sharing requirements. The bill applies to health plans, insurance policies, and contracts entered into or renewed after June 30, 2025, and includes an important exemption for brand-name prescription drugs that have a generic alternative, unless the individual has obtained access to the brand-name drug through prior authorization, step therapy protocol, or an exceptions/appeals process. A "generic alternative" is defined as a drug that is designated as therapeutically equivalent to the brand-name prescription drug by the Federal Food and Drug Administration and is nationally available. By mandating that all payments toward prescription drugs count toward out-of-pocket maximums, the bill aims to provide more transparency and potentially reduce financial burden for individuals purchasing prescription medications.
Committee Categories
Health and Social Services
Sponsors (3)
Last Action
Senators Ford J.D. and Yoder added as coauthors (on 01/14/2025)
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/435/details |
| BillText | https://iga.in.gov/pdf-documents/124/2025/senate/bills/SB0435/SB0435.01.INTR.pdf |
| Fiscal Note #1: Introduced | https://iga.in.gov/pdf-documents/124/2025/senate/bills/SB0435/fiscal-notes/SB0435.01.INTR.FN001.pdf |
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