South Carolina S 100: Pharmacy insurance benefits cost-sharing

Bill Text

2025-2026 Bill 100 Text of Previous Version (Dec. 12, 2024) - South Carolina Legislature Online 

South Carolina General Assembly
126th Session, 2025-2026

Bill 100

Indicates Matter Stricken
Indicates New Matter

(Text matches printed bills. Document has been reformatted to meet World Wide Web specifications.)

A bill

TO AMEND THE SOUTH CAROLINA CODE OF LAWS BY ADDING SECTION 
38-71-292 AND SECTION 38-71-820 BOTH SO AS TO DEFINE TERMS AND OUTLINE THE 
APPLICABILITY AND REQUIREMENTS FOR COST SHARING FOR INSURERS; BY ADDING SECTION 
38-71-2270 SO AS TO DEFINE TERMS AND OUTLINE THE APPLICABILITY AND REQUIREMENTS 
FOR COST SHARING FOR PHARMACY BENEFIT MANAGERS; AND BY AMENDING SECTION 
38-71-2200, RELATING TO DEFINITIONS CONCERNING PHARMACY BENEFITS MANAGERS, SO 
AS TO MAKE CONFORMING CHANGES.

Be it enacted by the General 
Assembly of the State of South Carolina:

SECTION 1. Article 1, Chapter 71, Title 38 of the S.C. Code is 
amended by adding:

 Section 
38-71-292. (A) As used in this 
section:

 (1) 
"Cost sharing" means any copayment, coinsurance, deductible, or other similar 
charges required of an enrollee for a healthcare service, including a 
prescription drug, covered by a health plan, and paid by or on behalf of such 
enrollee.

 (2) 
"Enrollee" means any individual entitled to healthcare services from an 
insurer.

 (3) 
"Health plan" means a policy, contract, certification, or agreement offered or 
issued by an insurer to provide, deliver, arrange for, pay for, or reimburse 
any of the costs of healthcare services.

 (4) 
"Healthcare service" means an item or service furnished to any individual for 
the purpose of preventing, alleviating, curing, or healing human illness, 
injury, or physical disability.

 (5) 
"Insurer" means an entity subject to the insurance laws and rules of insurance 
in this State or subject to the jurisdiction of the director that contracts, or 
offers to contract, to provide, deliver, arrange for, pay for, or reimburse any 
of the costs of healthcare services under a health plan in this State.

 (6) 
"Person" means a natural person, corporation, mutual company, unincorporated 
association, partnership, joint venture, limited liability company, trust, 
estate, foundation, not-for-profit corporation, unincorporated organization, 
government or governmental subdivision or agency.

 (B) 
The annual limitation on cost sharing provided for under 42 U.S.C. Section 
18022(c)(1) applies to all healthcare services covered under any health plan 
offered or issued by an insurer in this State.

 (C) 
When calculating an enrollee's contribution to any applicable cost-sharing 
requirement, an insurer shall include any cost-sharing amounts paid by the 
enrollee or on behalf of the enrollee by another person. If under federal law, 
application of this requirement would result in Health Savings Account 
ineligibility under Section 223 of the federal Internal Revenue Code, this 
requirement applies for Health Savings Account-qualified High Deductible Health 
Plans with respect to the deductible of such a plan after the enrollee has 
satisfied the minimum deductible under Section 223, except with respect to 
items or services that are preventive care pursuant to Section 223(c)(2)(C) of 
the federal Internal Revenue Code, in which case the requirements of this paragraph 
apply regardless of whether the minimum deductible under Section 223 has been 
satisfied.

 (D) 
Subsection (C) does not apply to a prescription drug for which there is a 
medically appropriate generic equivalent, unless the enrollee has obtained 
access to the brand name prescription drug through prior authorization, a step 
therapy protocol, the insurer's exceptions and appeals process, or as specified 
in Section 39-24-30(A).

 (E) 
An insurer shall not directly or indirectly set, alter, implement, or condition 
the terms of health plan coverage, including the benefit design, based in part 
or entirely on information about the availability or amount of financial or 
product assistance available for a prescription drug.

 (F) 
This section applies with respect to health plans that are entered into, 
amended, extended, or renewed on or after January 1, 2027.

 (G) 
In implementing the requirement of this section, the State shall only regulate 
an insurer or health benefit plan to the extent permissible under applicable 
law.

 (H) 
The director or his designee may promulgate rules and regulations as it deems 
necessary to implement this section.

SECTION 2. Article 5, Chapter 71, Title 38 of the S.C. Code is 
amended by adding:

 Section 
38-71-820. (A) As used in this 
section:

 (1) 
"Cost sharing" means any copayment, coinsurance, deductible, or other similar 
charges required of an enrollee for a healthcare service, including a 
prescription drug, covered by a health plan, and paid by or on behalf of such 
enrollee.

 (2) 
"Enrollee" means any individual entitled to health care services from an 
insurer.

 (3) 
"Health p