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Committee reviews raising hospital outpatient drug cap to 130% of average sales price; hospitals and insurer flag fiscal trade-offs
Summary
Legislative staff proposed amending Act 55 to raise the cap on hospital outpatient prescription drug reimbursement from 120% to 130% of average sales price; hospitals said the change could offset an estimated $6 million concern, while Blue Cross warned it could materially worsen the insurer’s financial position. The committee paused a vote to gather more numbers.
Legislative counsel Jennifer Carby told the committee the draft adds a provision amending Act 55’s cap on hospitals’ outpatient prescription drug reimbursement, which currently bars claims that exceed 120% of the average sales price (ASP) in effect as of 04/01/2025. "This would increase all of the 1 twenties to 1 thirties," Carby said, describing the technical change from 1.20 to 1.30.
Carby said the provision would apply to hospital outpatient and office settings where hospitals charge more than the ASP limit and that members had proposed staging the effective date. The draft as discussed tied the ASP adjustment to a mid‑year effective date (initially July 1, 2026) but members explored moving it to October 1 or January to ease implementation timing.
Committee members flagged a related fiscal trade‑off: the committee has a standing 3.5% commitment…
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