SB 167 — Prescription Drug Out-of-Pocket Expense Credit

SecondNOTE: Regular Session Seventy-fifth General Assembly STATE OF COLORADO REREVISED This Version Includes All Amendments Adopted in the Second House LLS NO.

26-0939.01This Edenbill Rollandhas x2373been SENATEprepared BILLfor 26-167the SENATEsignatures SPONSORSHIPof Benavidezthe andappropriate Mullica,legislative Amabile,officers Ball,and Coleman,the Cutter,Governor. Daugherty, Exum, Gonzales J., Hinrichsen, Jodeh, Kipp, Marchman, Snyder, Wallace, Weissman HOUSE SPONSORSHIP BoeseneckerandLindsay, Bacon,Brown,Camacho,Clifford,Duran,English,Gonzalez R., Hamrick, McCormick, Nguyen, Ricks, Rutinel, Rydin, Sirota d d e a 2 S n 2 U g 9 H d a e M Senate Committees House Committees R Health & Human Services Health & Human Services 3 Appropriations A BILL FOR AN ACT e n 6 C ONCERNING A COVERED PERSON 'S CONTRIBUTION UNDER A HEALTH E m 0 U n , BENEFIT PLAN BASED ON OUT -OF -POCKET EXPENSES O g y H i M ATTRIBUTABLE TO THE PURCHASE OF PRESCRIPTION DRUGS .

aTo Rdetermine nwhether Billthe SummaryGovernor ehas (Note:signed the bill or taken other action on it, please consult the legislative status sheet, the legislative history, or the Session Laws.

ThisSENATE summaryBILL applies26-167 toBY thisSENATOR(S) billBenavidez as introduced and doesMullica, nAmabile, notreflectanyamendmentsthatmaybesubsequentlyadopted.IfthisbillBall, mCutter, 6Daugherty, TExum, nGonzales 0J., passesHinrichsen, thirdJodeh, readingKipp, inMarchman, theSnyder, houseWallace, ofWeissman, introduction,Coleman; a bill summary that A U , applies to the reengrossed version of this bill will be available at E i y S a a http://leg.colorado.gov.) R M r Subject to certain exceptions, the bill requires a carrier of an individual or group health benefit plan in Colorado (plan), beginning on January1,2028,whencalculatingacoveredperson'soverallcontribution n toanout-of-pocketmaximumorcost-sharingrequirementundertheplan d e 6 (contribution), to account for and credit to the covered person's T R 0 A n , E d y Shading denotes HOUSE amendment.

Doublealso underliningREPRESENTATIVE(S) denotesBoesenecker SENATEand amendment.Lindsay, Bacon, Brown, Camacho, Clifford, Duran, English, Gonzalez R., Hamrick, McCormick, Nguyen, Ricks, Rutinel, Rydin, Sirota.

SC eONCERNING aA CapitalCOVERED lettersPERSON or'S boldCONTRIBUTION &UNDER italicA numbersHEALTH indicateBENEFIT newPLAN materialBASED toON beOUT added-OF to-POCKET existingEXPENSES law.nATTRIBUTABLE MTO DashesTHE throughPURCHASE theOF wordsPRESCRIPTION orDRUGS numbers. indicate deletions from existing law.

m A contribution an out-of-pocket expense that the covered person incurs by purchasing a prescription drug directly from a pharmacy, health-care provider, or direct-to-consumer platform (direct purchase of a prescription drug).

The carrier shall apply the credit to the covered person's contribution that is applicable in the plan year in which the expense from the direct purchase of a prescription drug was incurred.

To receive a contribution credit for an out-of-pocket expense that a covered person incurred because of a direct purchase of a prescription drug, the covered person must provide proof of payment to the carrier.

If the covered person does not provide proof of payment, the carrier is prohibited from applying the contribution credit.

The bill also prohibits a carrier from applying the contribution credit in certain other instances.

Specifically, the carrier shall not apply the contribution credit:

! For an amount of the covered person's out-of-pocket expensefromthedirectpurchaseofaprescriptiondrugthat is greater than the amount the covered person would have incurred if theyhad obtained the same prescription drug in the same plan year from an in-network pharmacy and pursuant to the terms of their plan;

! Ifthecoveredpersonincurredtheout-of-pocketexpenseby purchasingaprescriptiondrugthatisnotcoveredunderthe formularyofthecoveredperson'splan,unlessanexception is granted;

or ! If the covered person does not comply with the carrier's utilization management processes, including prior authorizationandsteptherapyprotocolsrequiredunderthe covered person's plan.

SECTION1.SECTION 1.

Shorttitle.Theshorttitleofthisactisthe"MakingShort HealthCareMoreAffordableThroughPrescriptionDrugPurchasesAct".title.

SECTION2.The short title of this act is the "Making Health Care More Affordable Through Prescription Drug Purchases Act".

InColoradoRevisedStatutes,10-16-161,add(2.5)SECTION as2. follows:

In Colorado Revised Statutes, 10-16-161, add (2.5) as follows:

(2.5)________ (a)Capital BGINNINGletters JANUARYor 1,2028,bold ANDEXCEPT& ASPROVIDEDitalic INSUBSECTIONnumbers (2.5)(dOFTHISSECTIONindicate ,WHENCALCULATINGACOVEREDnew -2-material 167added PERSONto Sexisting OVERALLlaw; CONTRIBUTION TO AN OU-OF-POCKET MAXIMUM OR COST-SHARING REQUIREMENT UNDER THE COVERED PERSON 'S HEALTH BENEFIT PLAN,A CARRIER THAT DELIVER,ISSUE,RENEWS ,AMENDS ,OR CONTINUES COVERAGE FOR AN INDIVIDUAL OR GROUP HEALTH BENEFIT PLAN IN THIS STATE SHALL ACCOUNT FOR AND CREDIT TO THE COVERED PERSON SOVERALLCONTRIBUTIONTOTHEOUT OF-POCKETMAXIMUMOR COST-SHARING REQUIREMENT AN OUT OF POCKET EXPENSE THAT THE COVERED PERSON INCURS BY:

(I)dashes PRCHASINGthrough Awords PRESCRIPTIONor DRUG;ANDnumbers (II)indicate DIRECTLYdeletions PAYINGfrom Aexisting PHARMACYlaw ORand DIRECT-TO-CONSUMERsuch PLATFORMmaterial FORis THEnot PRESCRIPTIONpart DRUG.of the act.

(b)(2.5)(a) NEGINNING ORDERJANUARY TO1,2028,ANDEXCEPTASPROVIDEDIN RECEIVESUBSECTION CREDIT(2.5)(d)OF FORTHIS SECTION,WHEN CALCULATING A COVERED PERSON S OVERALL CONTRIBUTION TO AN OUT -OF-POCKETOF EXPENSEPOCKET ASMAXIMUM DESCRIBEDOR INCOST-SHARING SUBSECTIONREQUIREMENT (2.5)(aOFUNDER THISTHE SECTION,ACOVERED COVEREDPERSONWHOPURCHASESAPRESCRIPTIONDRUGINACCORDANCEPERSON WITH'S SUBSECTIONHEALTH (2.5)(aOFBENEFIT THISPLAN,A SECTIONCARRIER SHALLTHAT PROVIDEDELIVERS TO,ISSUE, THERENEWS CARRIER,AMENDS PROOF,OR OFCONTINUESCOVERAGEFORANINDIVIDUALORGROUPHEALTHBENEFITPLAN PAYMENTINTHISSTATE SHALLACCOUNT FOR AND CREDIT TO THE COVEREDCOVEREDPERSON PERSONS'S PURCHASEOVERALL OFCONTRIBUTION TO THE PRESCRIPTIONOUT DRUG-OF-POCKET WITHINMAXIMUM NINETYOR DAYSCOST-SHARING AFTERREQUIREMENT MAKINGAN OUT -OF-POCKET EXPENSE THAT THE PURCHASECOVERED .PERSON INCURS BY :

S(I) UCHPRCHASING PROOFA OFPRESCRIPTION PURCHASEDRUG MAY;AND BE(II) SHOWNDIRECTLY BYPAYING DOCUMENTATIONOFTHEPURCHASEA ,INCLUDINGBYANITEMIZEDRECEIPTPHARMACY ORAPHARMACYRECORD .FTHEPROOFOFPURCHASETHATISSUBMITTED TO THE CARRIER IS INSUFFICIENT OR INCOMPLET,THEDIRECT CARRIER-TO-CONSUMER MAYPLATFORM REQUESTFOR ADDITIONALTHE INFORMATIONPRESCRIPTION ORDRUG. DOCUMENTATION .

(c)(b) AIN CARRIERORDER THATTO ACCOUNTSRECEIVE CREDIT FOR ANDAN CREDITSO-OF-POCKET AEXPENSE COVEREDASDESCRIBEDINSUBSECTION PERSON(2.5)(aOFTHISSECTION S,ACOVEREDPERSON OUT-OFPOCKETWHOPURCHASESAPRESCRIPTION EXPENSEDRUG IN ACCORDANCE WITHWITHSUBSECTION SUBSECTION(2.5)(a)OF (2.5)(a)F THIS SECTION SHALL APPLYPROVIDE TO THE CREDITCARRIER TOPROOF OF PAYMENT FOR THE COVERED PERSON S OVERALLPURCHASE CONTRIBUTIONOF TOTHE ANPRESCRIPTION OU-OF-POCKETDRUGWITHINNINETYDAYSAFTER MAXIMUMMAKING ORTHE COST-SHARINGPURCHASE REQUIREMENT.S UNDERUCH THEPROOFOF COVEREDPURCHASE PERSONMAY 'SBE HEALTHSHOWN -3-BY 167DOCUMENTATION BENEFITOF PLANTHE ,WHICHPURCHASE OUT, -OF-POCKETINCLUDINGBYANITEMIZEDRECEIPTORAPHARMACYRECORD MAXIMUM.FTHEPROOF OROF COSTPURCHASE SHARINGTHAT REQUIREMENT IS APPLICABLESUBMITTED INTO THE PLANCARRIER YEARIS ININSUFFICIENT WHICHOR THEINCOMPLETE OUT,THE OFCARRIER POCKETMAY EXPENSEREQUEST WASADDITIONAL INCURREDINFORMATION OR DOCUMENTATION .

(d)(c) A CARRIER SHALLTHAT NOTACCOUNTS CREDITFOR AND CREDITS A COVERED PERSON S OUTOUT-OF-POCKET OF POCKET EXPENSE IN ACCORDANCE WITH SUBSECTION (2.5)(aOF(2.5)(a)OF THIS SECTION:SECTION SHALL APPLY THE CREDIT TO THE COVERED PERSON S OVERALL CONTRIBUTION TO AN OUT OF-POCKET MAXIMUM OR COST-SHARING REQUIREMENT UNDER THE COVERED PERSON 'S HEALTH BENEFIT PLAN , WHICH OUT -OF-POCKET MAXIMUM OR COST -SHARING REQUIREMENT IS APPLICABLE IN THE PLAN YEAR IN WHICH THE OUT OF-POCKET EXPENSE WAS INCURRED .

(I)(d) FORA AN AMOUNT OF THE OUT-OFPOCKET EXPENSE INCURRED THAT IS GREATER THAN THE AMOUNT OF AN OUT OF-POCKET EXPENSE THAT THE COVERED PERSON WOULD HAVE INCURRED ,ACCORDING TO DRUG COST DATA AVAILABLE PURSUANT TO SECTION 10-16-122.9 (1)(c), IFTHECOVEREDPERSONHADOBTAINEDTHESAMEPRESCRIPTIONDRUGIN THE SAME PLAN YEAR FROM AN I-NETWORK PHARMACY AND PURSUANT TOTHETERMSOFTHECOVEREDPERSON SHEALTHBENEFITPLAN .INSUCH CIRCUMSTANCES , THE CARRIER SHALL APPLYNOT CREDIT FORA ONLYCOVERED THEPERSON AMOUNT'S THAT IS EQUAL TO OR LESS THAN THE AMOUNT OF THE OUT OFOF-POCKET POCKET EXPENSE THATIN THEACCORDANCE COVEREDWITH PERSONSUBSECTION WOULD(2.5)(aOF HAVETHIS INCURREDSECTION: ,ACCORDING TO DRUG COST DATA AVAILABLE PURSUANT TO SECTION 10-16-122.9(1)(cIFTHECOVEREDPERSONHADOBTAINEDTHE SAMEPRESCRIPTIONDRUGINTHESAMEPLANYEARFROMANIN NETWORK PHARMACY AND PURSUANT TO THE TERMS OF THE COVERED PERSON S HEALTH BENEFIT PLAN.

(II)PAGE I2-SENATE BILL 26-167 (I) FOR AN AMOUNT OF THE OUT OF POCKET EXPENSE INCURRED THATISGREATERTHANTHEAMOUNTOFANOUT OF POCKETEXPENSETHAT THE COVERED PERSON:PERSON WOULD HAVE INCURRED ,ACCORDING TO DRUG COST DATA AVAILABLE PURSUANT TO SECTION 10-16-122.9 (1)(c),IF THE COVERED PERSON HAD OBTAINED THE SAME PRESCRIPTION DRUG IN THE SAMEPLANYEARFROMANIN -NETWORKPHARMACYANDPURSUANTTOTHE TERMS OF THE COVERED PERSON S HEALTH BENEFIT PLAN .

(A)N DSUCH OESCIRCUMSTANCES NOT,THECARRIERSHALLAPPLYCREDITFORONLYTHEAMOUNT PROVIDETHAT PROOFIS EQUAL TO OR LESS THAN THE AMOUNT OF PAYMENTTHE PURSUANTOUT TO-OF-POCKET SUBSECTIONEXPENSE (2.5)(bOFTHAT THISTHE SECTIO;COVEREDPERSONWOULD HAVE INCURRED ,ACCORDING TODRUGCOSTDATAAVAILABLEPURSUANTTOSECTION 10-16-122.9(1)(c), IF THE COVERED PERSON HAD OBTAINED THE SAME PRESCRIPTION DRUG IN THESAMEPLANYEARFROMANIN -NETWORKPHARMACYANDPURSUANTTO THE TERMS OF THE COVERED PERSON 'S HEALTH BENEFIT PLAN.

(B)(II) INCURREDI THE OUT OF POCKET EXPENSE BY PURCHASING A PRESCRIPTION DRUG THAT IS NOT COVERED UNDER THE FORMULARY OF THE COVERED PERSON 'S: HEALTH BENEFIT PLAN,UNLESS THE CARRIER -4- 167 GRANTS AN EXCEPTION ;OR (C) DOES NOT COMPLY WITH THE CARRIER S UTILIZATION MANAGEMENT PROCESSES ,INCLUDING PRIOR AUTHORIZATION AND STEP THERAPY PROTOCOLS REQUIRED UNDER THE COVERED PERSON S PLAN.

(A) D OES NOT PROVIDE PROOF OF PAYMENT PURSUANT TO SUBSECTION (2.5)(b)OF THIS SECTIO;

(B) I NCURRED THE OUT -OFPOCKET EXPENSE BY PURCHASING A PRESCRIPTIONDRUGTHAT ISNOT COVEREDUNDERTHE FORMULARYOFTHE COVEREDPERSON 'SHEALTHBENEFITPLAN ,UNLESSTHECARRIERGRANTSAN EXCEPTION ;OR (C) D OES NOT COMPLY WITH THE CARRIER 'S UTILIZATION MANAGEMENT PROCESSES , INCLUDING PRIOR AUTHORIZATION AND STEP THERAPY PROTOCOLS REQUIRED UNDER THE COVERED PERSON S PLAN.

on the day following the expiration of the ninety-dayperiodafterfinaladjournmentofthegeneralassembly(Augustninety-dayperiod after final adjournment of the general assembly(August 12, 2026, if adjournment sine die is on May 13, 2026);

except that, if a referendumreferendumpetitionisfiledpursuanttosection1(3)ofarticleVofthestate petition is filed pursuant to section 1 (3) of article V of the state constitution against this act or an item, section, or part of this act within such period, then the act, item, section, or part will not take effect unless approvedPAGE by3-SENATE theBILL people26-167 atapprovedbythepeopleatthegeneralelectiontobeheldinNovember2026 the general election to be held in November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.

-5-____________________________ 167____________________________ James Rashad Coleman, Sr.

Julie McCluskie PRESIDENT OF SPEAKER OF THE HOUSE THE SENATE OF REPRESENTATIVES ____________________________ ____________________________ Esther van Mourik Vanessa Reilly SECRETARY OF CHIEF CLERK OF THE HOUSE THE SENATE OF REPRESENTATIVES APPROVED________________________________________ (Date and Time) _________________________________________ Jared S.

Polis GOVERNOR OF THE STATE OF COLORADO PAGE 4-SENATE BILL 26-167