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H 353

INSURANCE – Adds to existing law to establish certain cost-sharing requirements for health benefit plans.

68th Legislature, 1st Regular Session (2025)

The bill requires counting any third-party and manufacturer-provided assistance toward a enrollee’s prescription drug cost-sharing and mandates annual reporting of this aid to the

Reported Printed and Referred to Health & Welfare
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Bill Summary · H 353

Summary of Idaho House Bill H 353 (2025)

Overview

House Bill 353, introduced March 3, 2025, would add a new section (Idaho Code § 41-351) to regulate cost-sharing requirements for health benefit plans, with a focus on how third-party payments and manufacturer assistance for prescription drugs are counted toward an enrollee’s out-of-pocket costs. The bill is currently “Reported Printed and Referred to Health & Welfare” in the House.

Purpose and intent

  • To ensure that any payments made by a third party on behalf of an enrollee (including manufacturer discounts, coupons, rebates, or other financial assistance) are counted toward the enrollee’s cost-sharing obligations for prescription drugs.
  • To establish rules governing how manufacturer assistance is applied, disclosed, and reported to state regulators.
  • To provide a framework for transparency and monitoring of manufacturer-assisted cost-sharing reductions.

Key provisions

1) Definitions

  • Defines “cost-sharing requirement” as any copayment, coinsurance, deductible, or annual limit on cost-sharing for a covered health care service.

2) Calculation of cost-sharing for prescription drugs

  • When calculating an enrollee’s cost-sharing for a covered prescription drug, include payments made by:
    • The enrollee, and
    • Any third party acting on behalf of the enrollee.

3) Manufacturer assistance requirements

If a manufacturer provides financial assistance for a covered prescription drug:
- The full value of the assistance must be applied toward the enrollee’s cost-sharing until the enrollee meets their cost-sharing obligations, and continue to the enrollee’s health benefit plan thereafter.
- A coupon or assistance program may not be discontinued mid-year.
- The manufacturer must notify the enrollee by October 1 if financial assistance will be discontinued in the following year.
- Assistance must be available to uninsured individuals on terms no less favorable than those offered to insured individuals.
- If a recipient’s plan eliminates cost-sharing due to the on-behalf payments, the assistance cannot be adjusted.
- Assistance cannot be provided in the form of post-claim reimbursement to the enrollee.

4) Reporting by manufacturers

  • By August 1, 2027, and by August 1 annually thereafter, manufacturers must report to the Idaho Department of Insurance (DOI), for the preceding calendar year, for each drug with any cost-sharing-reducing assistance:
    • (a) Number of patients in Idaho receiving assistance
    • (b) Total value of the assistance
    • (c) Terms and eligibility verification criteria
    • (d) Total state sales of the drug based on wholesale acquisition cost

5) Effective date and applicability

  • The statute applies to health benefit plans entered into, amended, extended, or renewed on or after January 1, 2027.
  • For qualified high-deductible health plans (HDHPs), the cost-sharing requirements apply only after the enrollee has satisfied the deductible.

6) Exceptions

  • Excludes prescription drugs if there is a medically appropriate generic equivalent or biosimilar that is covered and prescribed as appropriate by a patient’s physician.

7) Rulemaking

  • The Idaho DOI may promulgate rules, with legislative approval, to implement the provisions.

Fiscal impact

  • The fiscal note indicates no net change in state revenue or expenditures; the bill would not impose additional state or local costs.

Who is affected

  • Enrollees and uninsured individuals receiving prescription drugs with manufacturer assistance.
  • Health benefit plans and insurers implementing drug cost-sharing.
  • Prescription drug manufacturers providing discount programs, coupons, rebates, or other financial assistance.
  • Idaho Department of Insurance for monitoring and reporting requirements.

Timeline and next steps

  • Effective date: January 1, 2027.
  • Annual reporting by August 1 each year, starting August 1, 2027.
  • Potential rulemaking by the DOI, subject to legislative approval.

This summary captures the bill’s core changes to cost-sharing reporting and the treatment of manufacturer-assistance in prescription drug costs, along with its scope and timeline.

Compiled from official sources — confirm details with the bill’s official record.

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