2023 -- H 5350 SUBSTITUTE A
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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
LC000200/SUB A/2 - Page 2 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 exceeds the threshold for a specialty 14
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and 15
Modernization Act of 2003 (Public Law 108-173)). 16
(5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a 17
cost-sharing obligation for a specialty drug. 18
(c) Every individual or group health insurance contract, plan or policy that provides 19
prescription drug coverage and is delivered, issued for delivery or renewed in this state on or after 20
January 1, 2025, shall limit any required copayment of coinsurance applicable to covered drugs on 21
a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for each 22
drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any copayment 23
or coinsurance. This limit shall be applicable after any deductible is reached and until the 24
individual's maximum out-of-pocket limit has been reached. 25
(d) Nothing in this section shall prevent an entity subject to this section from reducing a 26
covered individual's cost sharing for a specialty drug to an amount less than that described in section 27
(c) of this section. 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/SUB A/2 - 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 exceeds the threshold for a specialty 31
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and 32
Modernization Act of 2003 (Public Law 108-173)). 33
(5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a 34
LC000200/SUB A/2 - Page 4 of 8
cost-sharing obligation for a specialty drug. 1
(c) Every individual or group health insurance contract, plan or policy that provides 2
prescription drug coverage and is delivered, issued for delivery or renewed in this state on or after 3
January 1, 2025, shall limit any required copayment of coinsurance applicable to covered drugs on 4
a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for each 5
drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any copayment 6
or coinsurance. This limit shall be applicable after any deductible is reached and until the 7
individual's maximum out-of-pocket limit has been reached. 8
(d) Nothing in this section shall prevent an entity subject to this section from reducing a 9
covered individual's cost sharing for a specialty drug to an amount less than that described in section 10
(c) of this section. 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/SUB A/2 - 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 exceeds the threshold for a specialty 14
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and 15
Modernization Act of 2003 (Public Law 108-173)). 16
(5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a 17
cost-sharing obligation for a specialty drug. 18
(c) Every individual or group health insurance contract, plan or policy that provides 19
prescription drug coverage and is delivered, issued for delivery or renewed in this state on or after 20
January 1, 2025, shall limit any required copayment of coinsurance applicable to covered drugs on 21
a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for each 22
drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any copayment 23
or coinsurance. This limit shall be applicable after any deductible is reached and until the 24
individual's maximum out-of-pocket limit has been reached. 25
(d) Nothing in this section shall prevent an entity subject to this section from reducing a 26
covered individual's cost sharing for a specialty drug to an amount less than that described in section 27
(c) of this section. 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 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 33
Organizations" is hereby amended by adding thereto the following section: 34
LC000200/SUB A/2 - Page 6 of 8
27-41-38.3. 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 exceeds the threshold for a specialty 31
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and 32
Modernization Act of 2003 (Public Law 108-173)). 33
(5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a 34
LC000200/SUB A/2 - Page 7 of 8
cost-sharing obligation for a specialty drug. 1
(c) Every individual or group health insurance contract, plan or policy that provides 2
prescription drug coverage and is delivered, issued for delivery or renewed in this state on or after 3
January 1, 2025, shall limit any required copayment of coinsurance applicable to covered drugs on 4
a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for each 5
drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any copayment 6
or coinsurance. This limit shall be applicable after any deductible is reached and until the 7
individual's maximum out-of-pocket limit has been reached. 8
(d) Nothing in this section shall prevent an entity subject to this section from reducing a 9
covered individual's cost sharing for a specialty drug to an amount less than that described in section 10
(c) of this section. 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 5. This act shall take effect on January 1, 2025. 16
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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, 2025. 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 on January 1, 2025. 6
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