Cash-pay drug purchases could soon count toward insurance deductibles

Paying $1,500 a month for a medication when the same drug costs $15 in cash should count toward your insurance deductible—if you’re insured, you’ve already paid. That’s the core of a new plan from Rep. Greg Murphy (R-N.C.), who is pushing legislation requiring commercial insurers to apply cash-pay prescription drug purchases toward deductibles and out-of-pocket maximums. The policy targets a growing gap in health spending: when a drug’s cash price undercuts the insured copay, especially on direct-to-consumer platforms like TrumpRx or Mark Cuban’s CostPlusDrugs. Right now, patients who opt for lower cash prices forfeit progress toward their deductible—a barrier that discourages cost-saving behavior. Murphy’s bill would fix that, but only for drugs on a plan’s formulary and only for commercial insurance, not Medicare or Medicaid. The change would most directly benefit people in high-deductible health plans, who shoulder more upfront costs. Yet there’s a trade-off: requiring insurers to credit cash payments could lead to higher premiums. Harvard drug pricing researcher Benjamin Rome notes that new benefit mandates aren’t free. “If you're going to put additional requirements on insurers on how they're going to set their benefit design, that does have consequences,” he said. Some movement is already underway. Express Scripts, a major pharmacy benefit manager, must count TrumpRx purchases toward deductibles by 2027 under an FTC settlement. CVS Health hasn’t committed, but CEO David Joyner said the company would if it lowers costs. Insurers push back, arguing most people still get the lowest prices through insurance, not cash. Still, bipartisan frustration with health care pricing is mounting—and Murphy is testing multiple legislative paths, including a version focused solely on TrumpRx, to see what sticks.