Committee advances amendment to require copay assistance count toward patient cost-sharing; PBMs urge caution

The Senate Insurance Committee on Tuesday advanced an amended version of House Bill 1604 that would require pharmacy benefit managers (PBMs) and insurers to count manufacturer and charitable payments toward a patient’s deductible and out‑of‑pocket maximum for narrowly defined prescription categories.

Representative Daniel Smoltz, the amendment sponsor, told the committee the change "would, require PBMs and insurers to include shared payments from manufacturers and charitable organizations." He said the amendment includes an ERISA exclusion and “guardrails” limiting the measure to life‑saving drugs, drugs that manage chronic conditions and instances where no generic is available.

Supporters said the amendment targets patients with expensive, non‑generic therapies who face high upfront costs under high‑deductible plans. Vanessa Flora, who testified as a hemophilia patient and caregiver, said those programs are essential for her family: “Factor is very expensive. There are no generic options for hemophilia treatment. Our family's current cost per factor is 1,500,000.0 per year for 3 people just to keep us from…