Introduced Version
SENATE BILL No. 435
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 5-10-8-18.5; IC 27-1-24.5; IC 27-8-5-32;
IC 27-13-7-23.5.
Synopsis: Prohibition on copay accumulator adjustments. Provides
that under certain circumstances, the administrator of the state
employee health plan shall include any amount paid by a covered
individual or another person on behalf of the covered individual for a
prescription drug when calculating a covered individual's overall
contribution to an out-of-pocket maximum or cost sharing requirement
under the covered individual's state employee health plan. Provides that
under certain circumstances, a pharmacy benefit manager shall include
any amount paid by a covered individual or another person on behalf
of the covered individual for a prescription drug when calculating a
covered individual's overall contribution to an out-of-pocket maximum
or cost sharing requirement under the covered individual's health plan.
Provides that under certain circumstances, an insurer who issues a
policy of accident and sickness insurance shall include any amount
paid by an insured or another person on behalf of the insured for a
prescription drug when calculating an insured's overall contribution to
an out-of-pocket maximum or cost sharing requirement under the
insured's policy of accident and sickness insurance. Provides that under
certain circumstances, a health maintenance organization shall include
any amount paid by an enrollee or another person on behalf of the
enrollee for a prescription drug when calculating an enrollee's overall
contribution to an out-of-pocket maximum or cost sharing requirement
under the enrollee's individual or group contract.
Effective: July 1, 2025.
Hunley
January 13, 2025, read first time and referred to Committee on Health and Provider
Services.
2025 IN 435—LS 7299/DI 154 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.
SENATE BILL No. 435
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 5-10-8-18.5 IS ADDED TO THE INDIANA CODE
2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
3 1, 2025]: Sec. 18.5. (a) This section applies to a state employee
4 health plan that is established, entered into, amended, or renewed
5 after June 30, 2025.
6 (b) This section does not apply to an originating brand name
7 prescription drug for which a generic alternative exists, unless the
8 covered individual has obtained access to the originating brand
9 name drug through:
10 (1) prior authorization;
11 (2) a step therapy protocol; or
12 (3) the administrator's exceptions or appeals process.
13 (c) As used in this section, "administrator" has the meaning set
14 forth in section 11(a) of this chapter.
15 (d) As used in this section, "covered individual" means an
16 individual entitled to coverage under a state employee health plan.
17 (e) As used in this section, "generic alternative" means a drug
2025 IN 435—LS 7299/DI 154 2
1 that is:
2 (1) designated to be therapeutically equivalent to an
3 originating brand name prescription drug by the federal Food
4 and Drug Administration; and
5 (2) nationally available.
6 (f) As used in this section, "state employee health plan" means
7 the following:
8 (1) A self-insurance program established under section 7(b) of
9 this chapter.
10 (2) A contract for prepaid health care services entered into
11 under section 7(c) of this chapter.
12 (g) When calculating a covered individual's overall contribution
13 to an out-of-pocket maximum or cost sharing requirement under
14 the covered individual's state employee health plan, the
15 administrator shall include any amount paid by the covered
16 individual or another person on behalf of the covered individual
17 for a prescription drug.
18 SECTION 2. IC 27-1-24.5-3.7 IS ADDED TO THE INDIANA
19 CODE AS A NEW SECTION TO READ AS FOLLOWS
20 [EFFECTIVE JULY 1, 2025]: Sec. 3.7. As used in this chapter,
21 "generic alternative" means a drug that is:
22 (1) designated to be therapeutically equivalent to an
23 originating brand name prescription drug by the federal Food
24 and Drug Administration; and
25 (2) nationally available.
26 SECTION 3. IC 27-1-24.5-27.7 IS ADDED TO THE INDIANA
27 CODE AS A NEW SECTION TO READ AS FOLLOWS
28 [EFFECTIVE JULY 1, 2025]: Sec. 27.7. (a) This section applies to a
29 health plan entered into or renewed after June 30, 2025.
30 (b) This section does not apply to an originating brand name
31 prescription drug for which a generic alternative exists, unless the
32 covered individual has obtained access to the originating brand
33 name drug through:
34 (1) prior authorization;
35 (2) a step therapy protocol; or
36 (3) the pharmacy benefit manager's exceptions or appeals
37 process.
38 (c) When calculating a covered individual's overall contribution
39 to an out-of-pocket maximum or cost sharing requirement under
40 the covered individual's health plan, a pharmacy benefit manager
41 shall include any amount paid by the covered individual or another
42 person on behalf of the covered individual for a prescription drug.
2025 IN 435—LS 7299/DI 154 3
1 SECTION 4. IC 27-8-5-32 IS ADDED TO THE INDIANA CODE
2 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
3 1, 2025]: Sec. 32. (a) This section applies to a policy of accident and
4 sickness insurance that is issued, entered into, amended, or
5 renewed after June 30, 2025.
6 (b) This section does not apply to an originating brand name
7 prescription drug for which a generic alternative exists, unless the
8 insured has obtained access to the originating brand name drug
9 through:
10 (1) prior authorization;
11 (2) a step therapy protocol; or
12 (3) the insurer's exceptions or appeals process.
13 (c) As used in this section, "generic alternative" means a drug
14 that is:
15 (1) designated to be therapeutically equivalent to an
16 originating brand name prescription drug by the federal Food
17 and Drug Administration; and
18 (2) nationally available.
19 (d) As used in this section, "insured" means an individual
20 entitled to coverage under a policy of accident and sickness
21 insurance.
22 (e) As used in this section, "policy of accident and sickness
23 insurance" has the meaning set forth in section 1 of this chapter.
24 (f) When calculating an insured's overall contribution to an
25 out-of-pocket maximum or cost sharing requirement under the
26 insured's policy of accident and sickness insurance, an insurer shall
27 include any amount paid by the insured or another person on
28 behalf of the insured for a prescription drug.
29 SECTION 5. IC 27-13-7-23.5 IS ADDED TO THE INDIANA
30 CODE AS A NEW SECTION TO READ AS FOLLOWS
31 [EFFECTIVE JULY 1, 2025]: Sec. 23.5. (a) This section applies to an
32 individual contract and a group contract that is entered into,
33 delivered, amended, or renewed after June 30, 2025.
34 (b) This section does not apply to an originating brand name
35 prescription drug for which a generic alternative exists, unless the
36 enrollee has obtained access to the originating brand name
37 prescription drug through:
38 (1) prior authorization;
39 (2) a step therapy protocol; or
40 (3) the health maintenance organization's exceptions or
41 appeals process.
42 (c) As used in this section, "generic alternative" means a drug
2025 IN 435—LS 7299/DI 154 4
1 that is:
2 (1) designated to be therapeutically equivalent to an
3 originating brand name prescription drug by the federal Food
4 and Drug Administration; and
5 (2) nationally available.
6 (d) When calculating an enrollee's overall contribution to an
7 out-of-pocket maximum or cost sharing requirement under the
8 enrollee's individual or group contract, a health maintenance
9 organization shall include any amount paid by the enrollee or
10 another person on behalf of the enrollee for a prescription drug.
2025 IN 435—LS 7299/DI 154