Relating to the effect of certain reductions in a health benefit plan enrollee's out-of-pocket expenses for prescription drugs that are essential health benefits on the enrollee's cost-sharing requirements.

This Texas bill (SB 1287) requires health insurers to count certain out-of-pocket cost reductions for covered prescription drugs toward an enrollee’s overall cost-sharing limits (like deductibles or out-of-pocket maximums). It specifically applies when a patient accesses a drug without a generic equivalent or through prior authorization/step therapy, and the drug is classified as an "essential health benefit" under federal law. The rule applies only to health plans delivered, issued, or renewed on or after January 1, 2026. It directly affects Texas Medicaid and private plan enrollees who pay for covered drugs under these specific access scenarios.