SB 167

NOTE: This bill has been prepared for the signatures of the appropriate legislative
officers and the Governor. To determine whether the Governor has signed the bill
or taken other action on it, please consult the legislative status sheet, the legislative
history, or the Session Laws.
     SENATE BILL 26-167
     BY SENATOR(S) Benavidez and Mullica, Amabile, Ball, Cutter,
     Daugherty, Exum, Gonzales J., Hinrichsen, Jodeh, Kipp, Marchman,
     Snyder, Wallace, Weissman, Coleman;
     also REPRESENTATIVE(S) Boesenecker and Lindsay, Bacon, Brown,
     Camacho, Clifford, Duran, English, Gonzalez R., Hamrick, McCormick,
     Nguyen, Ricks, Rutinel, Rydin, Sirota.
     CONCERNING A COVERED PERSON'S CONTRIBUTION UNDER A HEALTH
          BENEFIT PLAN BASED ON OUT-OF-POCKET EXPENSES ATTRIBUTABLE
          TO THE PURCHASE OF PRESCRIPTION DRUGS.
     Be it enacted by the General Assembly of the State of Colorado:
           SECTION 1. Short title. The short title of this act is the "Making
     Health Care More Affordable Through Prescription Drug Purchases Act".
             SECTION 2. In Colorado Revised Statutes, 10-16-161, add (2.5)
     as follows:
            10-16-161. Calculation of contribution to out-of-pocket and
     cost-sharing requirements - exception - definition - rules.
     ________
     Capital letters or bold & italic numbers indicate new material added to existing law; dashes
     through words or numbers indicate deletions from existing law and such material is not part of
     the act.
       (2.5) (a) BEGINNING JANUARY 1, 2028, AND EXCEPT AS PROVIDED IN
SUBSECTION (2.5)(d) OF THIS SECTION, WHEN CALCULATING A COVERED
PERSON'S OVERALL CONTRIBUTION TO AN OUT-OF-POCKET MAXIMUM OR
COST-SHARING REQUIREMENT UNDER THE COVERED PERSON'S HEALTH
BENEFIT PLAN, A CARRIER THAT DELIVERS, ISSUES, RENEWS, AMENDS, OR
CONTINUES COVERAGE FOR AN INDIVIDUAL OR GROUP HEALTH BENEFIT PLAN
IN THIS STATE SHALL ACCOUNT FOR AND CREDIT TO THE COVERED PERSON'S
OVERALL CONTRIBUTION TO THE OUT-OF-POCKET MAXIMUM OR
COST-SHARING REQUIREMENT AN OUT-OF-POCKET EXPENSE THAT THE
COVERED PERSON INCURS BY:
      (I) PURCHASING A PRESCRIPTION DRUG; AND
      (II) DIRECTLY PAYING A PHARMACY OR DIRECT-TO-CONSUMER
PLATFORM FOR THE PRESCRIPTION DRUG.
       (b) IN ORDER TO RECEIVE CREDIT FOR AN OUT-OF-POCKET EXPENSE
AS DESCRIBED IN SUBSECTION (2.5)(a) OF THIS SECTION, A COVERED PERSON
WHO PURCHASES A PRESCRIPTION DRUG IN ACCORDANCE WITH SUBSECTION
(2.5)(a) OF THIS SECTION SHALL PROVIDE TO THE CARRIER PROOF OF
PAYMENT FOR THE COVERED PERSON'S PURCHASE OF THE PRESCRIPTION
DRUG WITHIN NINETY DAYS AFTER MAKING THE PURCHASE. SUCH PROOF OF
PURCHASE MAY BE SHOWN BY DOCUMENTATION OF THE PURCHASE,
INCLUDING BY AN ITEMIZED RECEIPT OR A PHARMACY RECORD. IF THE PROOF
OF PURCHASE THAT IS SUBMITTED TO THE CARRIER IS INSUFFICIENT OR
INCOMPLETE, THE CARRIER MAY REQUEST ADDITIONAL INFORMATION OR
DOCUMENTATION.
       (c) A CARRIER THAT ACCOUNTS FOR AND CREDITS A COVERED
PERSON'S OUT-OF-POCKET EXPENSE IN ACCORDANCE WITH SUBSECTION
(2.5)(a) OF THIS SECTION SHALL APPLY THE CREDIT TO THE COVERED
PERSON'S OVERALL CONTRIBUTION TO AN OUT-OF-POCKET MAXIMUM OR
COST-SHARING REQUIREMENT UNDER THE COVERED PERSON'S HEALTH
BENEFIT PLAN, WHICH OUT-OF-POCKET MAXIMUM OR COST-SHARING
REQUIREMENT IS APPLICABLE IN THE PLAN YEAR IN WHICH THE
OUT-OF-POCKET EXPENSE WAS INCURRED.
       (d) A CARRIER SHALL NOT CREDIT A COVERED PERSON'S
OUT-OF-POCKET EXPENSE IN ACCORDANCE WITH SUBSECTION (2.5)(a) OF
THIS SECTION:
PAGE 2-SENATE BILL 26-167
       (I) FOR AN AMOUNT OF THE OUT-OF-POCKET EXPENSE INCURRED
THAT IS GREATER THAN THE AMOUNT OF AN OUT-OF-POCKET EXPENSE THAT
THE COVERED PERSON WOULD HAVE INCURRED, ACCORDING TO DRUG COST
DATA AVAILABLE PURSUANT TO SECTION 10-16-122.9 (1)(c), IF THE
COVERED PERSON HAD OBTAINED THE SAME PRESCRIPTION DRUG IN THE
SAME PLAN YEAR FROM AN IN-NETWORK PHARMACY AND PURSUANT TO THE
TERMS OF THE COVERED PERSON'S HEALTH BENEFIT PLAN. IN SUCH
CIRCUMSTANCES, THE CARRIER SHALL APPLY CREDIT FOR ONLY THE AMOUNT
THAT IS EQUAL TO OR LESS THAN THE AMOUNT OF THE OUT-OF-POCKET
EXPENSE THAT THE COVERED PERSON WOULD HAVE INCURRED, ACCORDING
TO DRUG COST DATA AVAILABLE PURSUANT TO SECTION 10-16-122.9 (1)(c),
IF THE COVERED PERSON HAD OBTAINED THE SAME PRESCRIPTION DRUG IN
THE SAME PLAN YEAR FROM AN IN-NETWORK PHARMACY AND PURSUANT TO
THE TERMS OF THE COVERED PERSON'S HEALTH BENEFIT PLAN.
       (II) IF THE COVERED PERSON:
       (A)  DOES NOT PROVIDE PROOF OF PAYMENT PURSUANT TO
SUBSECTION (2.5)(b) OF THIS SECTION;
       (B) INCURRED THE OUT-OF-POCKET EXPENSE BY PURCHASING A
PRESCRIPTION DRUG THAT IS NOT COVERED UNDER THE FORMULARY OF THE
COVERED PERSON'S HEALTH BENEFIT PLAN, UNLESS THE CARRIER GRANTS AN
EXCEPTION; OR
     (C) DOES NOT COMPLY WITH THE CARRIER'S UTILIZATION
MANAGEMENT PROCESSES, INCLUDING PRIOR AUTHORIZATION AND STEP
THERAPY PROTOCOLS REQUIRED UNDER THE COVERED PERSON'S PLAN.
       SECTION 3. Act subject to petition - effective date. This act
takes effect at 12:01 a.m. on the day following the expiration of the
ninety-day period after final adjournment of the general assembly (August
12, 2026, if adjournment sine die is on May 13, 2026); except that, if a
referendum petition is filed pursuant to section 1 (3) of article V of the state
constitution against this act or an item, section, or part of this act within
such period, then the act, item, section, or part will not take effect unless
PAGE 3-SENATE BILL 26-167
approved by the people at the general election to be held in November 2026
and, in such case, will take effect on the date of the official declaration of
the vote thereon by the governor.
____________________________  ____________________________
James Rashad Coleman, Sr.  Julie McCluskie
PRESIDENT OF  SPEAKER OF THE HOUSE
THE SENATE  OF REPRESENTATIVES
____________________________  ____________________________
Esther van Mourik  Vanessa Reilly
SECRETARY OF  CHIEF CLERK OF THE HOUSE
THE SENATE  OF REPRESENTATIVES
       APPROVED________________________________________
                          (Date and Time)
                    _________________________________________
                   Jared S. Polis
                   GOVERNOR OF THE STATE OF COLORADO
PAGE 4-SENATE BILL 26-167