LUGPA Policy Brief – The Every Dollar Counts Act

May 2026

At-a-Glance Essentials

What’s Changing

• Requires commercial insurers to count patient spending on certain cash-pay prescription drugs toward deductibles and out-of-pocket maximums
• Applies to drugs purchased through direct-to-patient (DTP) platforms if on the plan’s formulary
• Excludes Medicare and Medicaid

Why It Matters

• Removes a key disincentive to using lower-cost purchasing options
• Improves affordability and adherence, especially for high-deductible health plan (HDHP) enrollees
• Increases competitive pressure on PBMs and traditional pricing models

Overview

The Every Dollar Counts Act, introduced by Rep. Greg Murphy, would require commercial insurers to credit patient spending on formulary-covered prescription drugs purchased through qualifying cash-pay platforms toward deductibles and out-of-pocket maximums.

Currently, patients who seek lower-cost drugs outside their insurance often receive no credit toward cost-sharing—forcing them to choose between higher insured prices or effectively “paying twice.” This bill aligns patient incentives with lower-cost options and supports broader efforts to improve drug affordability and transparency.

Background

High out-of-pocket costs—particularly in HDHPs—continue to limit medication access and adherence. In response, cash-pay and direct-to-patient platforms have expanded, offering lower prices by bypassing traditional PBM channels (e.g., federal initiatives like TrumpRx.gov and private platforms such as Cost Plus Drugs).

However, these purchases typically do not count toward insurance cost-sharing requirements, limiting their use. The legislation addresses this gap.

Key Provisions

• Crediting Requirement: Insurers must apply spending on eligible cash-pay drugs toward deductibles and out-of-pocket maximums
• Scope: Applies to commercial insurance only
• Formulary Limitation: Only formulary drugs qualify
• Platform Flexibility: Includes both public and private DTP/cash-pay models

Policy Context

The bill reflects broader momentum around drug pricing reform, including:

• Increased scrutiny of PBM practices
• Growth of direct purchasing models
• Early insurer exploration of similar crediting approaches

Some stakeholders have raised concerns about potential downstream effects, including premium or formulary adjustments.

Impact on LUGPA Members

Potential Benefits

• Improved adherence and reduced financial toxicity
• Greater flexibility to direct patients to lower-cost options
• Alignment with PBM reform and transparency efforts

Considerations

• Possible impact on in-office dispensing revenue
• Potential insurer responses (e.g., premium or formulary changes)
• Administrative complexity in verifying cash-pay transactions

LUGPA Perspective

The Every Dollar Counts Act advances market-based solutions to improve drug affordability and patient access. LUGPA supports policies that enhance transparency and preserve independent physician practices and will continue monitoring the legislation and its implications for urology care.