Bill > H6209

This bill modifies regulations for health insurance cost sharing by requiring insurers and pharmacy benefit managers (PBMs) to include all payments made by or on behalf of an enrollee when calculating their out-of-pocket maximum, specifically for prescription drugs that either have no generic equivalent or require special access methods like prior authorization, step therapy, or plan exceptions. The bill applies to health plans entered into or renewed on or after January 1, 2026, and includes a special provision for Health Savings Account (HSA) qualified High Deductible Health Plans to ensure compliance with federal tax rules. The legislation aims to provide more transparency in how patient costs are calculated and potentially reduce the financial burden on patients by counting all payments towards their out-of-pocket maximum, including those made by third parties such as charitable organizations, patient assistance programs, or other entities helping patients afford their medications. The bill also expands definitions related to health plans, insurers, and pharmacy benefit managers, providing clearer regulatory language for the healthcare industry.

Health and Social Services

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