HB 2652

PRIOR PRINTER'S NO. 3661  PRINTER'S NO.   3707
                THE GENERAL ASSEMBLY OF PENNSYLVANIA
                    HOUSE BILL
                    No. 2652
                                           Session of
                                             2026
INTRODUCED BY KINKEAD, McNEILL, PROBST, GUZMAN, HOWARD, SANCHEZ,
   HOHENSTEIN, DEASY, OTTEN, D. WILLIAMS AND CIRESI,
   JUNE 18, 2026
AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF
   REPRESENTATIVES, AS AMENDED, JUNE 24, 2026
                                AN ACT
1 Amending Title 40 (Insurance) of the Pennsylvania Consolidated
2    Statutes, providing for prescription drug cost credits in
3    health insurance; and imposing penalties.
4    The General Assembly of the Commonwealth of Pennsylvania
5 hereby enacts as follows:
6    Section 1.     Title 40 of the Pennsylvania Consolidated
7 Statutes is amended by adding a chapter to read:
8CHAPTER 52
9PRESCRIPTION DRUG COST CREDITS IN HEALTH INSURANCE
10 Sec.
11 5201.   Scope of chapter.
12 5202.   Definitions.
13 5203.   Prescription drug cost credit requirement.
14 5204.   Exceptions.
15 5205.   Protections.
16 5206.   Submission process.
17 5207.   Notice.
1 5208.   Exemption.
2 5209.   Regulations.
3 5210.   Enforcement.
4 § 5201.    Scope of chapter.
5    This chapter relates to the crediting of out-of-pocket costs
6 paid for prescription drugs toward health plan cost-sharing.
7 § 5202.    Definitions.
8    The following words and phrases when used in this chapter
9 shall have the meanings given to them in this section unless the
10 context clearly indicates otherwise:
11    "Commissioner."     The Insurance Commissioner of the
12 Commonwealth.
13    "Cost-sharing."     As follows:
14(1)   The share of the health care costs covered by a
15    health benefit plan that a covered person pays out-of-pocket.
16(2)   The term includes deductibles, coinsurance,
17    copayments and similar charges.
18(3)   The term does not include premiums, balance billed
19    amounts from an out-of-network health care provider or the
20    cost of noncovered services except as specified in this
21    chapter.
22    "Covered person."      A policyholder, subscriber or other
23 individual who is entitled to receive health care services under
24 a health benefit plan.
25    "Generically equivalent drug."        As defined in section 2 of
26 the act of November 24, 1976 (P.L.1163, No.259), known as the
27 Generic Equivalent Drug Law.
28    "Health benefit plan."      As defined in section 103 of the act
29 of November 21, 2016 (P.L.1318, No.169), known as the Pharmacy
30 Audit Integrity and Transparency Act.
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1    "Health care provider."    A person who is licensed, certified
2 or otherwise regulated to provide health care services under the
3 laws of this Commonwealth.
4    "Health care services."    Covered treatment, admission,
5 procedure, medical supplies and equipment or other services,
6 including behavioral health, prescribed or otherwise provided or
7 proposed to be provided by a health care provider to a covered
8 person for the diagnosis, prevention, treatment, cure or relief
9 of a health condition, illness, injury or disease under the
10 terms of a health benefit plan.
11    "Health insurer."   As defined in section 103 of the Pharmacy
12 Audit Integrity and Transparency Act.
13    "Health insurer client."    As defined in section 103 of the
14 Pharmacy Audit Integrity and Transparency Act.
15    "Interchangeable biological product."    As defined in section
16 2 of the Generic Equivalent Drug Law.
17    "Out-of-network provider."     A health care provider who does
18 not contract with a health insurer client to provide health care
19 services to a covered person under a health benefit plan.
20    "Pharmacy benefits manager."     As defined in section 103 of
21 the Pharmacy Audit Integrity and Transparency Act.
22    "Prescription drug."   The term shall include:
23(1)   A drug, a generically equivalent drug, a biological
24    product or an interchangeable biological product, as those
25    terms are defined in section 2 of the Generic Equivalent Drug
26    Law, that is prescribed by a health care provider.
27(2)   Insulin, insulin syringes and insulin needles.
28    "Prescription drug coverage administrator."    A health benefit
29 plan, health insurer or a pharmacy benefits manager that
30 administers pharmacy benefits for a health insurer client.
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1 § 5203.      Prescription drug cost credit requirement.
2(a)   Credits.--Except as provided in subsection (d), a
3 prescription drug coverage administrator shall credit toward the
4 covered person's in-network out-of-pocket maximum and other
5 cost-sharing requirements an out-of-pocket expense that the
6 covered person incurs by directly purchasing a prescription drug
7 from a pharmacy or through a discount drug purchasing entity.
8(b)   Application of credit.--The credit shall be applied to
9 the covered person's in-network out-of-pocket maximum for the
10 plan year in which the out-of-pocket expense is incurred and
11 without regard to whether:
12(1)   the pharmacy or discount drug purchasing entity has
13a contract or other arrangement with the prescription drug
14coverage administrator of the covered person's health benefit
15plan; or
16(2)   the health benefit plan has a separate out-of-
17network cost-sharing requirement or no out-of-network
18benefit.
19(c)   Proof of purchase requirement.--To receive credit for an
20 out-of-pocket expense as described in subsection (a), the
21 covered person shall submit proof of purchase to the
22 prescription drug coverage administrator in accordance with
23 section 5206 (relating to submission process).
24(d)   Limitation.--A prescription drug coverage administrator
25 may limit the amount of the credit of a covered person's out-of-
26 pocket expense in accordance with subsection (a) to the lesser
27 of:
28(1)   The amount the covered person incurred.
29(2)   The amount the covered person would have incurred if
30the covered person had obtained the same prescription drug in
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1    the same plan year from an in-network pharmacy and under the
2    terms of the covered person's health benefit plan.
3 § 5204.    Exceptions.
4    A prescription drug coverage administrator may decline to
5 credit a covered person's out-of-pocket expense as required in
6 section 5203 (relating to prescription drug cost credit
7 requirement) if:
8(1)   The covered person, or the covered person's provider
9    on the covered person's behalf, does not do both of the
10    following:
11(i)    Provide proof of purchase as required in
12sections 5203(b) and 5206 (relating to submission
13process).
14(ii)    Comply with the prescription drug coverage
15administrator's utilization management processes,
16including prior authorization and step therapy protocols
17required under the covered person's health benefit plan.
18(2)   The prescription drug is not covered under the
19    formulary of the covered person's health benefit plan, and no
20    drug exception has been granted.
21(3)   The prescription drug is experimental,
22    investigational or unsafe for the covered person.
23(4)   The prescription drug coverage administrator is
24    engaged in a reasonable investigation for, or has made a
25    finding of, fraud, waste or abuse with respect to the
26    prescribing health care professional or the covered person.
27 § 5205.    Protections.
28    Nothing in this chapter shall require a health benefit plan
29 to credit the cost share of a prescription drug in derogation of
30 a policyholder's constitutional protections of religious freedom
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1 under:
2(1)   The act of December 9, 2002 (P.L.1701, No.214),
3    known as the Religious Freedom Protection Act.
4(2)   42 U.S.C. Ch. 21B (relating to religious freedom
5    restoration).
6 § 5206.    Submission process.
7    (a)    Process required.--A prescription drug coverage
8 administrator shall establish a streamlined process for a
9 covered person to submit a request for credit of the covered
10 person's payment for a prescription drug to the covered person's
11 contribution to a cost-sharing requirement under a health
12 benefit plan.
13    (b)    Process requirements.--The submission process:
14(1)   Shall be described in a manner that complies with
15    the language requirements of 42 U.S.C. §§ 18031(e)(3)(B)
16    (relating to affordable choices of health benefits plans) and
17    18116 (relating to nondiscrimination) and their regulations,
18    including 45 CFR Subt. A Subch. A Pt. 92 (relating to
19    nondiscrimination in health programs or activities) and
20    Subch. B Pts. 149 (relating to surprise billing and
21    transparency requirements), 155 (relating to exchange
22    establishment standards and other related standards under the
23    Affordable Care Act) and 156 (relating to health insurance
24    issuer standards under the Affordable Care Act, including
25    standards related to exchanges).
26(2)   Shall be available at a minimum both in the covered
27    person's health benefit plan and on the health insurer's
28    publicly accessible Internet website.
29(3)   Shall permit submission both through electronic
30    means and by mail.
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1(4)   May require submission of satisfactory proof of
2    purchase, including evidence of the purchase date and amount
3    and the identification of the prescription drug purchased.
4    Examples of satisfactory proof of purchase include a dated
5    and itemized receipt or a pharmacy record.
6(5)   May require that the covered person submit proof of
7    purchase no later than 90 days after the purchase.
8(6)   Must be operational by no later than 180 days after
9    the effective date of this paragraph.
10 § 5207.    Notice.
11    (a)    Maximum out-of-pocket.--Within 10 business days of
12 becoming aware that a covered person reached the person's in-
13 network maximum out-of-pocket limit, a prescription drug
14 coverage administrator shall notify the covered person that the
15 covered person's health benefit plan will pay 100% of covered
16 costs for the remainder of the year at an in-network pharmacy
17 and that reimbursement for out-of-pocket purchases of covered
18 drugs will not be paid to the covered person.
19    (b)    Limitation.--Nothing in this chapter shall require a
20 prescription drug coverage administrator to make payment to a
21 covered person to reimburse an out-of-pocket purchase of a
22 prescription drug once the covered person's maximum out-of-
23 pocket limit is reached.
24 § 5208.    Exemption.
25    (a)    Exemption.--The requirements of this chapter shall not
26 apply to a prescription drug coverage administrator that
27 contracts or has an arrangement with a pharmacy or discount drug
28 purchasing entity that makes available a transparent pricing
29 model to covered persons, if the prescription drug coverage
30 administrator makes available all drugs covered under the terms
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1 of the covered person's health benefit plan that are offered
2 from that pharmacy or discount drug purchasing entity as part of
3 the contract or arrangement with the health benefit plan.
4    (B)   LOSS OF EXEMPTION.--A PRESCRIPTION DRUG COVERAGE  <--
5 ADMINISTRATOR THAT NO LONGER QUALIFIES FOR THE EXEMPTION UNDER
6 THIS SECTION SHALL COMPLY WITH ALL APPLICABLE REQUIREMENTS OF
7 THIS CHAPTER WITHIN 60 DAYS AFTER THE DATE ON WHICH THE
8 PRESCRIPTION DRUG COVERAGE ADMINISTRATOR FAILS TO MEET THE
9 REQUIREMENTS FOR THE EXEMPTION, WHICH MAY BE EXTENDED AT THE
10 DISCRETION OF THE COMMISSIONER.
11    (b) (C)     Definitions.--As used in this section, the following <--
12 words and phrases shall have the meanings given to them in this
13 subsection unless the context clearly indicates otherwise:
14    "Transparent pricing model."        A pricing arrangement made
15 available to a covered person, directly or through a pharmacy
16 benefits manager, pharmacy network or other contracted entity,
17 that meets all of the following requirements:
18(1)   The price for a prescription drug is both:
19(i)    Disclosed to the covered person in advance of
20purchase.
21(ii)    Based on a clearly defined formula or
22methodology, including a cost-plus, fixed markup or
23similar methodology, that is not contingent on post-sale
24rebates, retrospective adjustments or other undisclosed
25financial considerations.
26(2)   The covered person is able to purchase the
27    prescription drug at the disclosed price.
28(3)   Any applicable fees, markups or dispensing charges
29    are identifiable to the covered person in advance of
30    purchase.
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1 § 5209.    Regulations.
2    The department may promulgate regulations as necessary and
3 appropriate to carry out the provisions of this chapter.
4 § 5210.    Enforcement.
5    (a)    Penalties.--After satisfactory evidence of the violation
6 of this chapter by a prescription drug coverage administrator,
7 one or more of the following penalties may be imposed at the
8 commissioner's discretion:
9(1)   Suspension or revocation of the offending entity's
10    license or registration.
11(2)   Refusal, for a period not to exceed one year, to
12    issue a new license or registration to the offending entity.
13(3)   A fine of not more than $5,000 for each violation of
14    this chapter.
15(4)   A fine of not more than $10,000 for each willful
16    violation of this chapter.
17    (b)    Limitation.--Fines imposed against an entity under this
18 section may not exceed $500,000 in the aggregate during a single
19 calendar year.
20    (c)    Additional remedies.--The enforcement remedies imposed
21 under this section are in addition to any other remedies or
22 penalties that may be imposed under any other applicable law of
23 this Commonwealth, including:
24(1)   The act of July 22, 1974 (P.L.589, No.205), known as
25    the Unfair Insurance Practices Act. A violation of this
26    chapter shall be deemed to be an unfair method of competition
27    and an unfair or deceptive act or practice under the Unfair
28    Insurance Practices Act.
29(2)   The act of December 18, 1996 (P.L.1066, No.159),
30    known as the Accident and Health Filing Reform Act.
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1(3)   The act of June 25, 1997 (P.L.295, No.29), known as
2    the Pennsylvania Health Care Insurance Portability Act.
3(4)   The act of November 21, 2016 (P.L.1318, No.169),
4    known as the Pharmacy Audit Integrity and Transparency Act.
5    (d)   Administrative procedure.--The administrative provisions
6 of this chapter shall be subject to 2 Pa.C.S. Ch. 5 Subch. A
7 (relating to practice and procedure of Commonwealth agencies). A
8 party against whom penalties are assessed in an administrative
9 action may appeal to Commonwealth Court as provided in 2 Pa.C.S.
10 Ch. 7 Subch. A (relating to judicial review of Commonwealth
11 agency action).
12    Section 2.     This act shall apply as follows:
13(1)   For health benefit plans for which either rates or
14    forms are required to be filed with the department, the
15    addition of 40 Pa.C.S. Ch. 52 shall apply to any policy for
16    which a form or rate is first filed on or after the effective
17    date of this paragraph.
18(2)   For health benefit plans for which neither rates nor
19    forms are required to be filed with the department, the
20    addition of 40 Pa.C.S. Ch. 52 shall apply to any policy
21    issued or renewed on or after 180 days after the effective
22    date of this paragraph.
23    Section 3.     This act shall take effect in 60 days.
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