Introduced Version
HOUSE BILL No. 1252
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 27-1.
Synopsis: Limitation on cost sharing. Requires an insurer, an
administrator, and a pharmacy benefit manager to apply the annual
limitation on cost sharing set forth in the federal Patient Protection and
Affordable Care Act under 42 U.S.C. 18022(c)(1). Provides that an
insurer, an administrator, and a pharmacy benefit manager may not
directly or indirectly set, alter, implement, or condition the terms of
health insurance coverage based in part or entirely on information
about the availability or amount of financial or product assistance
available for a prescription drug. Requires, before December 31 of each
year, each insurer and administrator to certify to the insurance
commissioner that the insurer or administrator has fully and completely
complied with the cost sharing requirements during the previous
calendar year.
Effective: January 1, 2026.
Smaltz, Lehman, McGuire
January 9, 2025, read first time and referred to Committee on Insurance.
2025 IN 1252—LS 7280/DI 141 Introduced
First Regular Session of the 124th General Assembly (2025)
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
Constitution) is being amended, the text of the existing provision will appear in this style type,
additions will appear in this style type, and deletions will appear in this style type.
Additions: Whenever a new statutory provision is being enacted (or a new constitutional
provision adopted), the text of the new provision will appear in this style type. Also, the
word NEW will appear in that style type in the introductory clause of each SECTION that adds
a new provision to the Indiana Code or the Indiana Constitution.
Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
between statutes enacted by the 2024 Regular Session of the General Assembly.
HOUSE BILL No. 1252
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
Be it enacted by the General Assembly of the State of Indiana:
1 SECTION 1. IC 27-1-24.5-0.8 IS ADDED TO THE INDIANA
2 CODE AS A NEW SECTION TO READ AS FOLLOWS
3 [EFFECTIVE JANUARY 1, 2026]: Sec. 0.8. As used in this chapter,
4 "cost sharing" means any copayment, coinsurance, deductible, or
5 other similar charge that is:
6 (1) required of a covered individual for a health care service
7 covered by a health plan, including a prescription drug; and
8 (2) paid:
9 (A) by; or
10 (B) on behalf of;
11 the covered individual.
12 SECTION 2. IC 27-1-24.5-4.5 IS ADDED TO THE INDIANA
13 CODE AS A NEW SECTION TO READ AS FOLLOWS
14 [EFFECTIVE JANUARY 1, 2026]: Sec. 4.5. As used in this chapter,
15 "health care service" means a service or good furnished for the
16 purpose of preventing, alleviating, curing, or healing:
17 (1) human illness;
2025 IN 1252—LS 7280/DI 141 2
1 (2) physical disability; or
2 (3) injury.
3 SECTION 3. IC 27-1-24.5-5, AS AMENDED BY P.L.207-2021,
4 SECTION 52, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
5 JANUARY 1, 2026]: Sec. 5. As used in this chapter, "health plan"
6 means a plan through which coverage is provided for health care
7 services through insurance, prepayment, reimbursement, or
8 otherwise. The term includes the following:
9 (1) A state employee health plan (as defined in IC 5-10-8-6.7).
10 (2) A policy of accident and sickness insurance (as defined in
11 IC 27-8-5-1). However, the term does not include the coverages
12 described in IC 27-8-5-2.5(a).
13 (3) An individual contract (as defined in IC 27-13-1-21) or a
14 group contract (as defined in IC 27-13-1-16) that provides
15 coverage for basic health care services (as defined in
16 IC 27-13-1-4).
17 (4) Any other plan or program that provides payment,
18 reimbursement, or indemnification to a covered individual for the
19 cost of prescription drugs.
20 SECTION 4. IC 27-1-24.5-6.5 IS ADDED TO THE INDIANA
21 CODE AS A NEW SECTION TO READ AS FOLLOWS
22 [EFFECTIVE JANUARY 1, 2026]: Sec. 6.5. As used in this chapter,
23 "insurer" means an insurer subject to state law and rules
24 regulating insurance or subject to the jurisdiction of the
25 department that contracts, or offers to contract, to:
26 (1) provide;
27 (2) deliver;
28 (3) arrange for;
29 (4) pay for; or
30 (5) reimburse;
31 any of the costs of health care services to a covered individual
32 under a health plan.
33 SECTION 5. IC 27-1-24.5-11.5 IS ADDED TO THE INDIANA
34 CODE AS A NEW SECTION TO READ AS FOLLOWS
35 [EFFECTIVE JANUARY 1, 2026]: Sec. 11.5. As used in this chapter,
36 "pharmacy benefit management services" means:
37 (1) negotiating the price of prescription drugs, including
38 negotiating and contracting for direct or indirect rebates,
39 discounts, or other price concessions;
40 (2) managing any aspect of a prescription drug benefit,
41 including:
42 (A) the processing and payment of claims for prescription
2025 IN 1252—LS 7280/DI 141 3
1 drugs;
2 (B) arranging alternative access to or funding for
3 prescription drugs;
4 (C) the performance of drug utilization review;
5 (D) the processing of drug prior authorization requests;
6 (E) the adjudication of appeals or grievances related to the
7 prescription drug benefit;
8 (F) contracting with network pharmacies;
9 (G) controlling the cost of covered prescription drugs;
10 (H) managing or providing data relating to the
11 prescription drug benefit;
12 (I) the provision of services related to the prescription drug
13 benefit; or
14 (J) creating or updating prescription drug formularies;
15 (3) performance of any administrative, managerial, clinical,
16 pricing, financial, reimbursement, data administration or
17 reporting, or billing service; and
18 (4) any other services specified in a rule adopted by the
19 department.
20 SECTION 6. IC 27-1-24.5-12, AS AMENDED BY P.L.32-2021,
21 SECTION 77, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
22 JANUARY 1, 2026]: Sec. 12. (a) As used in this chapter, "pharmacy
23 benefit manager" means: an entity that, on behalf of a health plan, state
24 agency, insurer, managed care organization, or other third party payor:
25 (1) a person who, under a written agreement with an insurer,
26 health plan, state agency, managed care organization, or other
27 third party payor, directly or indirectly provides one (1) or
28 more pharmacy benefit management services on behalf of the
29 insurer, health plan, state agency, managed care organization,
30 or other third party payor; and
31 (2) an agent, a contractor, an intermediary, an affiliate, a
32 subsidiary, or a related entity of a person described in
33 subdivision (1) who facilitates, provides, directs, or oversees
34 the provision of the pharmacy benefit management services.
35 (1) contracts directly or indirectly with pharmacies to provide
36 prescription drugs to individuals;
37 (2) administers a prescription drug benefit;
38 (3) processes or pays pharmacy claims;
39 (4) creates or updates prescription drug formularies;
40 (5) makes or assists in making prior authorization determinations
41 on prescription drugs;
42 (6) administers rebates on prescription drugs; or
2025 IN 1252—LS 7280/DI 141 4
1 (7) establishes a pharmacy network.
2 (b) The term does not include the following:
3 (1) A person licensed under IC 16.
4 (2) A health provider who is:
5 (A) described in IC 25-0.5-1; and
6 (B) licensed or registered under IC 25.
7 (3) A consultant who only provides advice concerning the
8 selection or performance of a pharmacy benefit manager.
9 SECTION 7. IC 27-1-24.5-20, AS AMENDED BY P.L.158-2024,
10 SECTION 8, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
11 JANUARY 1, 2026]: Sec. 20. (a) The commissioner shall do the
12 following:
13 (1) Prescribe an application for use in applying for a license to
14 operate as a pharmacy benefit manager.
15 (2) Adopt rules under IC 4-22-2 to establish the following:
16 (A) Pharmacy benefit manager licensing requirements.
17 (B) Licensing fees.
18 (C) A license application.
19 (D) Financial standards for pharmacy benefit managers.
20 (E) Reporting requirements described in sections 21 and 29 of
21 this chapter.
22 (F) The time frame for the resolution of an appeal under
23 section 22 of this chapter.
24 (b) The commissioner may do the following:
25 (1) Charge a license application fee and renewal fees established
26 under subsection (a)(2) in an amount not to exceed five hundred
27 dollars ($500) to be deposited in the department of insurance fund
28 established by IC 27-1-3-28.
29 (2) Examine or audit the books and records of a pharmacy benefit
30 manager one (1) time per year to determine if the pharmacy
31 benefit manager is in compliance with this chapter.
32 (3) Adopt rules under IC 4-22-2 to:
33 (A) implement this chapter; and
34 (B) specify requirements for the following:
35 (i) Prohibited market conduct practices.
36 (ii) Data reporting in connection with violations of state law.
37 (iii) Maximum allowable cost list compliance and
38 enforcement requirements, including the requirements of
39 sections 22 and 23 of this chapter.
40 (iv) Prohibitions and limits on pharmacy benefit manager
41 practices that require licensure under IC 25-22.5.
42 (v) Pharmacy benefit manager affiliate information sharing.
2025 IN 1252—LS 7280/DI 141 5
1 (vi) Lists of health plans administered by a pharmacy benefit
2 manager in Indiana.
3 (vii) Pharmacy benefit management services included
4 under section 11.5(4) of this chapter.
5 (c) Financial information and proprietary information submitted by
6 a pharmacy benefit manager to the department is confidential.
7 SECTION 8. IC 27-1-24.5-27.7 IS ADDED TO THE INDIANA
8 CODE AS A NEW SECTION TO READ AS FOLLOWS
9 [EFFECTIVE JANUARY 1, 2026]: Sec. 27.7. (a) This section applies
10 to a health plan that is issued, delivered, amended, or renewed
11 after December 31, 2025.
12 (b) A pharmacy benefit manager shall apply the annual
13 limitation on cost sharing set forth in the federal Patient Protection
14 and Affordable Care Act under 42 U.S.C. 18022(c)(1) to all health
15 care services covered under a health plan administered by the
16 pharmacy benefit manager.
17 (c) Except as provided in subsection (d), when calculating a
18 covered individual's contribution to an applicable cost sharing
19 requirement, a pharmacy benefit manager must include any cost
20 sharing amounts paid:
21 (1) by the covered individual; or
22 (2) on behalf of the covered individual by another person.
23 (d) If application of subsection (c) would result in a covered
24 individual becoming ineligible for a health savings account under
25 Section 223 of the Internal Revenue Code, the requirement under
26 subsection (c) applies with respect to the deductible of a high
27 deductible health plan after the covered individual satisfies the
28 minimum deductible under Section 223 of the Internal Revenue
29 Code. However, subsection (c) applies to items or services that are
30 preventative care under Section 223(c)(2)(C) of the Internal
31 Revenue Code regardless of whether the minimum deductible
32 under Section 223 of the Internal Revenue Code is satisfied.
33 (e) A pharmacy benefit manager may not directly or indirectly:
34 (1) set;
35 (2) alter;
36 (3) implement; or
37 (4) condition;
38 the terms of health plan coverage, including the benefit design,
39 based in part or entirely on information about the availability or
40 amount of financial or product assistance available for a
41 prescription drug.
42 SECTION 9. IC 27-1-51 IS ADDED TO THE INDIANA CODE AS
2025 IN 1252—LS 7280/DI 141 6
1 A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE
2 JANUARY 1, 2026]:
3 Chapter 51. Cost Sharing for Health Insurance Coverage
4 Sec. 1. This chapter applies to a policy of health insurance
5 coverage that is issued, delivered, amended, or renewed after
6 December 31, 2025.
7 Sec. 2. As used in this chapter, "administrator" means a person
8 who, directly or indirectly and on behalf of an insurer:
9 (1) underwrites;
10 (2) collects charges or premiums from or adjusts or settles
11 claims on:
12 (A) residents of Indiana; or
13 (B) residents of another state from offices in Indiana;
14 in connection with health insurance coverage offered or provided
15 by an insurer.
16 Sec. 3. As used in this chapter, "cost sharing" means any
17 copayment, coinsurance, deductible, or other similar charge that
18 is:
19 (1) required of a covered individual for a health care service
20 covered by a policy of health insurance coverage, including a
21 prescription drug; and
22 (2) paid:
23 (A) by; or
24 (B) on behalf of;
25 the covered individual.
26 Sec. 4. As used in this chapter, "covered individual" means an
27 individual who is entitled to health insurance coverage.
28 Sec. 5. As used in this chapter, "health care service" means a
29 service or good furnished for the purpose of preventing,
30 alleviating, curing, or healing:
31 (1) human illness;
32 (2) physical disability; or
33 (3) injury.
34 Sec. 6. (a) As used in this chapter, "health insurance coverage"
35 means:
36 (1) an individual or group policy of accident and sickness
37 insurance (as defined in IC 27-8-5-1);
38 (2) an individual contract (as defined in IC 27-13-1-21) or a
39 group contract (as defined in IC 27-13-1-16) that provides
40 coverage for basic health care services (as defined in
41 IC 27-13-1-4); and
42 (3) any other health plan that is issued on an individual or
2025 IN 1252—LS 7280/DI 141 7
1 group basis;
2 that is subject to state law and rules regulating insurance or
3 subject to the jurisdiction of the department. The term includes
4 coverage of a dependent of the covered individual under a policy
5 or contract described in subdivisions (1) through (3).
6 (b) The term does not include a self-funded health benefit plan
7 that complies with the federal Employee Retirement Income
8 Security Act (ERISA) of 1974 (29 U.S.C. 1001 et seq.).
9 Sec. 7. As used in this chapter, "insurer" means an insurer that
10 provides health insurance coverage to a covered individual.
11 Sec. 8. As used in this chapter, "person" means a natural
12 person, corporation, mutual company, unincorporated association,
13 partnership, joint venture, limited liability company, trust, estate,
14 foundation, not-for-profit corporation, unincorporated
15 organization, government, or governmental subdivision or agency.
16 Sec. 9. An insurer and an administrator shall apply the annual
17 limitation on cost sharing set forth in the federal Patient Protection
18 and Affordable Care Act under 42 U.S.C. 18022(c)(1) to all health
19 care services covered under a policy or contract of health
20 insurance coverage offered or issued by the insurer.
21 Sec. 10. (a) Except as provided in subsection (b), when
22 calculating a covered individual's contribution to an applicable
23 cost sharing requirement, an insurer and administrator must
24 include any cost sharing amounts paid:
25 (1) by the covered individual; and
26 (2) on behalf of the covered individual by another person.
27 (b) If application of subsection (a) would result in a covered
28 individual becoming ineligible for a health savings account under
29 Section 223 of the Internal Revenue Code, the requirement under
30 subsection (a) applies with respect to the deductible of a high
31 deductible health plan after the covered individual satisfies the
32 minimum deductible under Section 223 of the Internal Revenue
33 Code. However, subsection (a) applies to items or services that are
34 preventative care under Section 223(c)(2)(C) of the Internal
35 Revenue Code regardless of whether the minimum deductible
36 under Section 223 of the Internal Revenue Code is satisfied.
37 Sec. 11. An insurer and an administrator may not directly or
38 indirectly:
39 (1) set;
40 (2) alter;
41 (3) implement; or
42 (4) condition;
2025 IN 1252—LS 7280/DI 141 8
1 the terms of health insurance coverage, including the benefit
2 design, based in part or entirely on information about the
3 availability or amount of financial or product assistance available
4 for a prescription drug.
5 Sec. 12. Before December 31 of each year, each insurer and
6 administrator shall certify to the commissioner that the insurer or
7 administrator has fully and completely complied with the
8 requirements of this chapter during the previous calendar year.
9 The certification must be signed by the chief executive officer or
10 chief financial officer of the insurer or administrator.
11 Sec. 13. The commissioner may adopt rules under IC 4-22-2 to
12 implement this chapter.
2025 IN 1252—LS 7280/DI 141