Bill
HB 1681
Missouri now requires health plans and PBMs to count patient payments toward cost-sharing when no generic substitute exists, reducing out-of-pocket limits.
Status & timeline (key dates)
- Introduced: December 19, 2024.
- Advanced through committee and floor action in spring 2025.
- Enrolled and transmitted to the Governor; recorded as Act 812 (notification dated April 17, 2025).
- Statutory section added: Missouri Revised Statutes chapter 376, new section 376.448.
- Applicability: applies to health benefit plans entered into, amended, extended, or renewed on or after August 28, 2026.
Purpose
- To require health carriers and pharmacy benefits managers (PBMs) to include certain patient payments for medications in enrollees’ cost‑sharing totals and to prohibit plan design that penalizes enrollees because cost‑sharing assistance is available for medications without generic equivalents.
Key provisions
- Definitions: establishes terms including “cost‑sharing,” “enrollee,” “generic drug,” “health benefit plan,” “health carrier,” and “pharmacy benefits manager.” (References cross‑defined to existing statutory sections and federal regulation.)
- Counting payments toward out‑of‑pocket (OOP) and cost‑sharing totals: carriers and PBMs must include any amounts paid by the enrollee or paid on behalf of the enrollee for a medication when a generic substitute is not available when calculating the enrollee’s contribution to any OOP maximum or cost‑sharing requirement.
- Prohibition on benefit design based on assistance: carriers and PBMs may not vary an enrollee’s OOP maximum or other cost‑sharing requirements based on the existence or availability of third‑party cost‑sharing assistance programs for medications without generic substitutes.
- HSA/HDHP exception: if complying with subsection (counting payments) would make a plan ineligible for Health Savings Account (HSA) status under federal law (Internal Revenue Code §223), the counting requirement applies only after the enrollee has satisfied the minimum deductible required for HSA‑qualified high‑deductible plans — except that preventive care items/services remain subject to the counting rule regardless of deductible status.
- Other: preserves the use of step therapy (prior authorization/step protocols). Excludes plans governed by the Labor Management Relations Act (ERISA‑covered employer plans).
Who is affected
- Health carriers (insurers) and pharmacy benefits managers operating in Missouri.
- Enrollees in state‑regulated health benefit plans (not ERISA self‑insured employer plans).
- Manufacturers or third parties providing copay or patient assistance — their payments may now be required to be credited toward an enrollee’s OOP totals when no generic exists.
Potential impact and implementation considerations
- Intended to reduce the effective out‑of‑pocket burden for patients who use brand medications without generic alternatives by ensuring payments made on their behalf count toward caps.
- Could affect plan and PBM accounting, claims processing, and contracts with manufacturers regarding copay assistance.
- Carriers may respond with changes to benefit design, premiums, or cost control strategies, subject to statutory prohibitions.
- Federal tax rules (HSA eligibility) constrain full application to HSA‑qualified HDHPs until minimum deductibles are met.
Note: ERISA‑covered employer self‑insured plans remain outside this statute’s scope; they are governed by federal law.
Compiled from official sources — confirm details with the bill’s official record.
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