Representative Karen Carls presented House Bill 12-16, which would prohibit health plans from excluding third‑party assistance (manufacturer coupons or nonprofit help) from applying to a patient’s out‑of‑pocket maximum for covered prescription drugs.

Nut graf: The sponsor described the bill as targeted relief for patients with rare or high‑cost conditions who rely on manufacturer or nonprofit assistance to cover initial cost sharing. PERS told the committee the bill, as drafted, applies broadly to brand (tier‑2 and tier‑3) prescriptions in state and political‑subdivision plans and that Deloitte’s actuarial analysis produced a fiscal note showing millions in additional cost for the upcoming biennium. Committee members discussed funding options, including using PERS’ reserves, before voting 4–1 to forward the bill.

Rebecca Frikey, executive director of PERS, said Deloitte priced the bill assuming the language requires co‑payments for tier‑2 or tier‑3 prescriptions to count toward a members’ prescription coinsurance maximum and then toward the medical out‑of‑pocket maximum. Because the PERS grandfathered plan design currently treats some prescription cost-sharing separately, applying all brand prescription co‑payments to out‑of‑pocket maximums would shift costs into the plan during the 24‑month biennium used in the fiscal-note calculation. Frikey said the actuary could not quantify the portion of co‑payments that are currently covered by third‑party coupons because PERS does not track coupon usage at that level.

Committee members discussed alternatives and funding sources. Senator Davison noted the PERS health‑trust reserve (about $55 million) could be used if the Legislature chose to authorize it; Rebecca Frikey confirmed reserves can be used to buy down premiums or pay for benefit enhancements but warned using reserves reduces funds available in the next premium cycle.

At the end of the hearing the committee voted to recommend the bill to the full committee. The roll call was: Senator Clary — yes; Senator Davison — yes; Chairman Deaver — yes; Senator Magrum — no; Senator Mather — yes (4–1).

Ending: The bill will move forward with a due‑pass recommendation. Committee members asked PERS and staff to provide updated fiscal estimates if the bill is amended to narrow its scope to specific high‑cost conditions or to include a pilot run through the PERS plan-design pilot required for insurance mandates.