Concerning a covered person's contribution under a health benefit plan based on out-of-pocket expenses attributable to the purchase of prescription drugs.
Summary
SB26-167 requires Colorado health insurers, beginning January 1, 2028, to count certain out-of-pocket prescription drug purchases made directly by a covered person toward that person’s deductible, out-of-pocket maximum, or other cost-sharing requirement. The bill applies when a person buys a prescription drug directly from a pharmacy, health-care provider, or direct-to-consumer platform and provides proof of payment to the carrier. The credit must be applied to the plan year in which the expense was incurred.
The bill also sets limits on when a carrier must recognize these expenses. A carrier may not credit amounts above what the person would have paid for the same drug through an in-network pharmacy under the plan, may deny credit for drugs not covered by the plan formulary unless an exception is granted, and may deny credit if the person did not follow utilization management requirements such as prior authorization or step therapy. The act is titled the “Making Health Care More Affordable Through Prescription Drug Purchases Act” and takes effect after the referendum period, absent a petition.
Impact
The bill amends Colorado Revised Statutes section 10-16-161 to add a new subsection governing how carriers calculate a covered person’s contribution toward out-of-pocket and cost-sharing limits in individual and group health benefit plans. It creates a new obligation for insurers to credit qualifying direct-purchase prescription drug expenses toward plan cost-sharing, while preserving existing plan controls over formulary coverage, utilization management, and cost comparisons to in-network pharmacy pricing. The law applies to carriers delivering, issuing, renewing, amending, or continuing health coverage in Colorado and is effective for plan years beginning on or after January 1, 2028.
Sentiment
The bill appears generally favorable in purpose and framing, as reflected by its title and its advancement to final enactment with the governor’s signature. Its stated goal is to make health care more affordable by ensuring consumers receive cost-sharing credit for prescription drug purchases made outside the traditional pharmacy benefit channel. No committee transcript or recorded vote information was provided, so there is no detailed evidence of opposition or support beyond the bill’s enacted status.
Contention
The main points of contention are likely to center on insurer administration and cost controls. Carriers may object to having to credit direct-to-consumer or cash purchases toward deductibles and out-of-pocket maximums, especially where the purchase price exceeds in-network plan pricing. The bill also preserves disputes over whether a drug is on formulary and whether the patient complied with prior authorization or step therapy, which could affect how often credits are denied. Consumer advocates would likely support broader crediting of prescription spending, while insurers and pharmacy benefit administrators may emphasize fraud prevention, documentation requirements, and maintaining utilization management.