Relating to financial assistance available for a prescription drug
HB3092 amends multiple chapters of West Virginia insurance law to change how health plans count cost sharing and to limit how prescription drug financial assistance can affect coverage decisions. The bill requires insurers and pharmacy benefits managers, when calculating an insured’s contribution toward deductibles, copayments, coinsurance, and other cost-sharing limits, to count amounts paid by the insured or paid on the insured’s behalf by another person. It also extends the annual federal cost-sharing limitation to all covered health care services under health plans issued in the state, subject to federal high-deductible health plan and health savings account rules.
The bill further prohibits insurers, pharmacy benefits managers, and third-party administrators from directly or indirectly setting or changing health plan terms, including benefit design, based on the availability or amount of financial or product assistance for a prescription drug. It authorizes the Insurance Commissioner to adopt implementing rules and establishes civil penalties of up to $10,000 per violation, along with possible restitution to affected persons. The amendments are set to apply to policy years beginning on or after January 1, 2026, while preserving the bill’s stated interaction with federal HSA-qualified high-deductible plan requirements.
HB3092 would affect insurers, pharmacy benefits managers, third-party administrators, and health plans regulated under West Virginia’s accident and sickness insurance, group insurance, hospital service corporation, health care corporation, and HMO statutes. It changes how cost-sharing accumulators are applied by requiring third-party payments toward prescription or other covered services to count toward a member’s deductible or out-of-pocket limit, and it bars coverage design decisions that respond to patient assistance programs for drugs. The bill also creates an enforcement mechanism through the Insurance Commissioner, including civil penalties and restitution, and it may require conforming rulemaking.
The available voting history suggests the bill was generally well received in the House, passing 80-3 on March 28, 2025. That margin indicates broad support for the bill’s consumer-protection and affordability goals, especially its effort to ensure that financial assistance helps patients meet their cost-sharing obligations rather than being disregarded by insurers. No committee transcript is available, so the record does not show detailed debate, but the vote suggests the measure was not broadly controversial among House members.
The main points of contention are likely to center on the bill’s effect on insurer benefit design, pharmacy benefits management practices, and the treatment of prescription drug assistance programs. Insurers and PBMs may view the accumulator-style requirement and the ban on using assistance information in coverage decisions as limiting their ability to manage plan costs and design formularies, while supporters would frame those provisions as preventing patients from being penalized for using manufacturer or charitable assistance. Another possible issue is the interaction with federal HSA-qualified high-deductible health plan rules, which the bill addresses by carving out federal compliance exceptions.