Summary#

SB 26-167, officially the Making Health Care More Affordable Through Prescription Drug Purchases Act, amends Colorado Revised Statutes section 10-16-161. Its stated goal is to make prescription drug purchases count toward a person’s health-plan out-of-pocket maximum or cost-sharing requirement. The supplied status lists the bill as signed into law; the credit rule begins January 1, 2028.

• Starting then, health insurers (called “carriers” in the bill) must credit eligible out-of-pocket spending when calculating a covered person’s plan-year total.
• The rule applies when the person buys a prescription drug and pays a pharmacy or a direct-to-consumer platform directly.
• The person must send proof of payment within 90 days. An itemized receipt or pharmacy record may be used.
• The credit is limited to what the person would have paid for the same drug at an in-network pharmacy under the plan. No credit is required for a non-formulary drug unless the carrier grants an exception, or if the person has not followed plan rules such as prior authorization or step therapy.
• The law does not provide cash back or require the carrier to cover the full amount paid.

What it means for you#

• People with health plans: If you pay directly for an eligible prescription, you must submit proof within 90 days to receive credit toward your plan’s out-of-pocket maximum or cost-sharing requirement.
• People buying non-formulary drugs or not following plan rules: The bill does not require a credit in those circumstances, unless the carrier grants an exception for a non-formulary drug.
• Health insurers: Starting January 1, 2028, carriers that issue, renew, amend, continue, or deliver individual or group health plans in Colorado must apply qualifying credits to the plan-year total.
• People with other types of coverage: The bill text names individual and group health benefit plans. It does not explain whether or how other coverage arrangements are treated. The parent law was not supplied, so I could not verify how this provision fits with current law.

Money#

No cost information is in the available material.

• The bill does not state a public spending amount, fee, or tax change.
• Carriers must account for eligible expenses, but the bill gives no estimate of their administrative or staffing costs.
• It does not require reimbursement of the full purchase price; the credit is capped at the amount the person would have paid in-network under the plan.

What is unclear#

• The bill does not set a deadline for carriers to apply a credit after receiving proof, or explain how a person can challenge a denial.
• It does not explain how carriers must determine the in-network amount using the referenced drug cost data.
• The bill text does not define “direct-to-consumer platform.” The supplied materials do not include the parent law, so I could not check whether that law defines the term or sets related rules.
• The act’s general effective date is the day after 90 days following final adjournment; the text gives August 12, 2026, only if adjournment was May 13, 2026. The credit requirement itself starts January 1, 2028.

Case for#

• A possible argument for the bill is that people who pay a pharmacy or platform directly should still be able to count eligible spending toward their plan’s out-of-pocket limit.
• Requiring proof and capping the credit at the in-network amount may let carriers verify claims while limiting the credit to what the plan would have charged in-network.
• Applying the credit to the plan year in which the expense occurred ties it to the relevant plan-year limit.

Case against#

• One concern is that a person may pay more than the in-network amount but receive credit only up to that lower amount.
• The 90-day proof deadline could prevent a credit if someone misses it or cannot provide enough documentation.
• The bill excludes non-formulary drugs and expenses when plan utilization rules were not followed, so some direct purchases will not count.
• It is unclear how quickly credits must be applied and what recourse a person has if a carrier rejects proof or calculates the credit incorrectly.