2023 -- H 5350
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LC000200
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S TATE OF RHODE IS LAND
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2023
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A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
Introduced By: Representatives Morales, Chippendale, Kislak, McNamara, Place,
Kazarian, Spears, Donovan, Potter, and Newberry
Date Introduced: February 03, 2023
Referred To: House Health & Human Services
It is enacted by the General Assembly as follows:
SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance 1
Policies" is hereby amended by adding thereto the following section: 2
27-18-50.2. Specialty drugs. 3
(a) The general assembly makes the following findings: 4
(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 5
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 6
residents had two (2) or more chronic diseases, which significantly increases their likelihood to 7
depend on prescription specialty drugs; 8
(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 9
prescription drug as prescribed due to cost; 10
(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 11
create competition and help lower their prices; and 12
(4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the 13
negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 14
(b) As used in this section, the following words shall have the following meanings: 15
(1) "Complex or chronic medical condition" means a physical, behavioral, or 16
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 17
advances over time, and: 18
(i) May have no known cure; 19
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(ii) Is progressive; or 1
(iii) Can be debilitating or fatal if left untreated or undertreated. 2
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 3
hepatitis c, and rheumatoid arthritis. 4
(2) "Pre-service authorization" means a cost containment method that an insurer, a 5
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 6
coverage for drugs prescribed by a health care provider for a covered individual to control 7
utilization, quality, and claims. 8
(3) "Rare medical condition" means a disease or condition that affects fewer than: 9
(i) Two hundred thousand (200,000) individuals in the United States; or 10
(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 11
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 12
multiple myeloma. 13
(4) "Specialty drug" means a prescription drug that: 14
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 15
medical condition; and 16
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 17
specialty tier threshold, as updated from time to time. 18
(c) Every individual or group health insurance contract, plan or policy that provides 19
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 20
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 21
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 22
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 23
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 24
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 25
(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 26
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 27
fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 28
(e) The health insurance commissioner may promulgate any rules and regulations 29
necessary to implement and administer this section in accordance with any federal requirements 30
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 31
this section. 32
SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 33
Corporations" is hereby amended by adding thereto the following section: 34
LC000200 - Page 3 of 8
27-19-42.1. Specialty drugs. 1
(a) The general assembly makes the following findings: 2
(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 3
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 4
residents had two (2) or more chronic diseases, which significantly increases their likelihood to 5
depend on prescription specialty drugs; 6
(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 7
prescription drug as prescribed due to cost; 8
(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 9
create competition and help lower their prices; and 10
(4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the 11
negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 12
(b) As used in this section, the following words shall have the following meanings: 13
(1) "Complex or chronic medical condition" means a physical, behavioral, or 14
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 15
advances over time, and: 16
(i) May have no known cure; 17
(ii) Is progressive; or 18
(iii) Can be debilitating or fatal if left untreated or undertreated. 19
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 20
hepatitis c, and rheumatoid arthritis. 21
(2) "Pre-service authorization" means a cost containment method that an insurer, a 22
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 23
coverage for drugs prescribed by a health care provider for a covered individual to control 24
utilization, quality, and claims. 25
(3) "Rare medical condition" means a disease or condition that affects fewer than: 26
(i) Two hundred thousand (200,000) individuals in the United States; or 27
(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 28
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 29
multiple myeloma. 30
(4) "Specialty drug" means a prescription drug that: 31
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 32
medical condition; and 33
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 34
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specialty tier threshold, as updated from time to time. 1
(c) Every individual or group health insurance contract, plan or policy that provides 2
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 3
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 4
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 5
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 6
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 7
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 8
(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 9
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 10
fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 11
(e) The health insurance commissioner may promulgate any rules and regulations 12
necessary to implement and administer this section in accordance with any federal requirements 13
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 14
this section. 15
SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 16
Corporations" is hereby amended by adding thereto the following section: 17
27-20-37.1. Specialty drugs. 18
(a) The general assembly makes the following findings: 19
(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 20
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 21
residents had two (2) or more chronic diseases, which significantly increases their likelihood to 22
depend on prescription specialty drugs; 23
(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 24
prescription drug as prescribed due to cost; 25
(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 26
create competition and help lower their prices; and 27
(4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the 28
negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 29
(b) As used in this section, the following words shall have the following meanings: 30
(1) "Complex or chronic medical condition" means a physical, behavioral, or 31
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 32
advances over time, and: 33
(i) May have no known cure; 34
LC000200 - Page 5 of 8
(ii) Is progressive; or 1
(iii) Can be debilitating or fatal if left untreated or undertreated. 2
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 3
hepatitis c, and rheumatoid arthritis. 4
(2) "Pre-service authorization" means a cost containment method that an insurer, a 5
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 6
coverage for drugs prescribed by a health care provider for a covered individual to control 7
utilization, quality, and claims. 8
(3) "Rare medical condition" means a disease or condition that affects fewer than: 9
(i) Two hundred thousand (200,000) individuals in the United States; or 10
(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 11
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 12
multiple myeloma. 13
(4) "Specialty drug" means a prescription drug that: 14
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 15
medical condition; and 16
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 17
specialty tier threshold, as updated from time to time. 18
(iii) Is not typically stocked at retail pharmacies; and 19
(iv)(A) Requires a difficult or unusual process of delivery to the patient in the preparation, 20
handling, storage, inventory, or distribution of the drug; or 21
(B) Requires enhanced patient education, management, or support, beyond those required 22
for traditional dispensing, before or after administration of the drug. 23
(c) Every individual or group health insurance contract, plan or policy that provides 24
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 25
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 26
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 27
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 28
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 29
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 30
(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 31
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 32
fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 33
(e) The health insurance commissioner may promulgate any rules and regulations 34
LC000200 - Page 6 of 8
necessary to implement and administer this section in accordance with any federal requirements 1
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 2
this section. 3
SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 4
Organizations" is hereby amended by adding thereto the following section: 5
27-41-38.3. Specialty drugs. 6
(a) The general assembly makes the following findings: 7
(1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents 8
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) 9
residents had two (2) or more chronic diseases, which significantly increases their likelihood to 10
depend on prescription specialty drugs; 11
(2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a 12
prescription drug as prescribed due to cost; 13
(3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to 14
create competition and help lower their prices; and 15
(4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the 16
negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug. 17
(b) As used in this section, the following words shall have the following meanings: 18
(1) "Complex or chronic medical condition" means a physical, behavioral, or 19
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 20
advances over time, and: 21
(i) May have no known cure; 22
(ii) Is progressive; or 23
(iii) Can be debilitating or fatal if left untreated or undertreated. 24
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 25
hepatitis c, and rheumatoid arthritis. 26
(2) "Pre-service authorization" means a cost containment method that an insurer, a 27
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 28
coverage for drugs prescribed by a health care provider for a covered individual to control 29
utilization, quality, and claims. 30
(3) "Rare medical condition" means a disease or condition that affects fewer than: 31
(i) Two hundred thousand (200,000) individuals in the United States; or 32
(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 33
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 34
LC000200 - Page 7 of 8
multiple myeloma. 1
(4) "Specialty drug" means a prescription drug that: 2
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 3
medical condition; and 4
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 5
specialty tier threshold, as updated from time to time. 6
(c) Every individual or group health insurance contract, plan or policy that provides 7
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 8
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 9
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 10
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 11
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 12
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 13
(d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 14
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 15
fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 16
(e) The health insurance commissioner may promulgate any rules and regulations 17
necessary to implement and administer this section in accordance with any federal requirements 18
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 19
this section. 20
SECTION 5. This act shall take effect upon passage. 21
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
***
This act would limit the copayment or coinsurance requirement on specialty drugs to one 1
hundred fifty dollars ($150) for a thirty (30)-day supply regarding any specialty drug in any 2
individual or health insurance contract, plan or policy issued, delivered or renewed on or after 3
January 1, 2024. Specialty drugs would be defined as a drug prescribed to an individual with a 4
complex or chronic medical condition or a rare medical condition. 5
This act would take effect upon passage. 6
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LC000200
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