2023 -- S 0870
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LC002496
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S T A T E O F R H O D E I S L A N D
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2023
____________
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
Introduced By: Senators Ujifusa, Miller, Lawson, Valverde, Lauria, Kallman, Zurier,
DiMario, Euer, and DiPalma
Date Introduced: March 30, 2023
Referred To: Senate 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
27-18-33.3. Patient choice in dispensing of clinician-administered drugs. 3
(a) As used in this section: 4
(1) "Clinician-administered drug" means an outpatient prescription drug other than a 5
vaccine that: 6
(i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed 7
or by an individual assisting the patient with the self-administration; and 8
(ii) Is typically administered: 9
(A) By a health care provider authorized under the laws of this state to administer the drug, 10
including when acting under a physician's delegation and supervision; and 11
(B) In a physician's office, hospital outpatient infusion center, or other clinical setting. 12
(b) A health benefit issuer or pharmacy benefit manager: 13
(1) Shall not refuse to authorize, approve, or pay a participating provider for providing 14
covered clinician-administered drugs and related services to covered persons; 15
(2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an 16
additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other 17
penalty when obtaining clinician-administered drugs from a health care provider authorized under 18
the laws of this state to administer clinician-administered drugs, or a pharmacy; 19
LC002496 - Page 2 of 8
(3) Shall not interfere with the patient's right to choose to obtain a clinician-administered 1
drug from their provider or pharmacy of choice, including inducement, steering, or offering 2
financial or other incentives; 3
(4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected 4
by the health plan or create such a requirement through contract with a third party, including, but 5
not limited to, a pharmacy benefit manager; 6
(5) Shall not limit or exclude coverage for a clinician-administered drug when not 7
dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered; 8
(6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a 9
pharmacy not selected by the health plan or create such an arrangement through contract with a 10
third party, including, but not limited to, a pharmacy benefit manager; 11
(7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to 12
a participating provider for providing covered clinician-administered drugs and related services to 13
covered persons when all criteria for medical necessity are met, because the participating provider 14
obtains clinician-administered drugs from a pharmacy that is not a participating provider in the 15
health benefit issuer's network; 16
(8) Shall not require that an enrollee pay an additional fee, higher copay, higher 17
coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-18
administered drugs when not dispensed by a pharmacy selected by the health plan or create such a 19
requirement through contract with a third party, including, but not limited to, a pharmacy benefit 20
manager; 21
(9) Shall not require a specialty pharmacy to dispense a clinician-administered medication 22
directly to a patient with the intention that the patient will transport the medication to a healthcare 23
provider for administration. 24
(c) A health benefit issuer may offer, but shall not require, either directly or through 25
contract with a third party, including, but not limited to, a pharmacy benefit manager: 26
(1) The use of a home infusion pharmacy to dispense clinician-administered drugs to 27
patients in their homes or; 28
(2) The use of an infusion site external to a patient's provider office or clinic. 29
SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 30
Corporations" is hereby amended by adding thereto the following section: 31
27-19-26.3. Patient choice in dispensing of clinician-administered drugs. 32
(a) As used in this section: 33
(1) "Clinician-administered drug" means an outpatient prescription drug other than a 34
LC002496 - Page 3 of 8
vaccine that: 1
(i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed 2
or by an individual assisting the patient with the self-administration; and 3
(ii) Is typically administered: 4
(A) By a health care provider authorized under the laws of this state to administer the drug, 5
including when acting under a physician's delegation and supervision; and 6
(B) In a physician's office, hospital outpatient infusion center, or other clinical setting. 7
(b) A health benefit issuer or pharmacy benefit manager: 8
(1) Shall not refuse to authorize, approve, or pay a participating provider for providing 9
covered clinician-administered drugs and related services to covered persons; 10
(2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an 11
additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other 12
penalty when obtaining clinician-administered drugs from a health care provider authorized under 13
the laws of this state to administer clinician-administered drugs, or a pharmacy; 14
(3) Shall not interfere with the patient's right to choose to obtain a clinician-administered 15
drug from their provider or pharmacy of choice, including inducement, steering, or offering 16
financial or other incentives; 17
(4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected 18
by the health plan or create such a requirement through contract with a third party, including, but 19
not limited to, a pharmacy benefit manager; 20
(5) Shall not limit or exclude coverage for a clinician-administered drug when not 21
dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered; 22
(6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a 23
pharmacy not selected by the health plan or create such an arrangement through contract with a 24
third party, including, but not limited to, a pharmacy benefit manager; 25
(7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to 26
a participating provider for providing covered clinician-administered drugs and related services to 27
covered persons when all criteria for medical necessity are met, because the participating provider 28
obtains clinician-administered drugs from a pharmacy that is not a participating provider in the 29
health benefit issuer's network; 30
(8) Shall not require that an enrollee pay an additional fee, higher copay, higher 31
coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-32
administered drugs when not dispensed by a pharmacy selected by the health plan or create such a 33
requirement through contract with a third party, including, but not limited to, a pharmacy benefit 34
LC002496 - Page 4 of 8
manager; 1
(9) Shall not require a specialty pharmacy to dispense a clinician-administered medication 2
directly to a patient with the intention that the patient will transport the medication to a healthcare 3
provider for administration. 4
(c) A health benefit issuer may offer, but shall not require, either directly or through 5
contract with a third party, including, but not limited to, a pharmacy benefit manager: 6
(1) The use of a home infusion pharmacy to dispense clinician-administered drugs to 7
patients in their homes or; 8
(2) The use of an infusion site external to a patient's provider office or clinic. 9
SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 10
Corporations" is hereby amended by adding thereto the following section: 11
27-20-23.3. Patient choice in dispensing of clinician-administered drugs. 12
(a) As used in this section: 13
(1) "Clinician-administered drug" means an outpatient prescription drug other than a 14
vaccine that: 15
(i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed 16
or by an individual assisting the patient with the self-administration; and 17
(ii) Is typically administered: 18
(A) By a health care provider authorized under the laws of this state to administer the drug, 19
including when acting under a physician's delegation and supervision; and 20
(B) In a physician's office, hospital outpatient infusion center, or other clinical setting. 21
(b) A health benefit issuer or pharmacy benefit manager: 22
(1) Shall not refuse to authorize, approve, or pay a participating provider for providing 23
covered clinician-administered drugs and related services to covered persons; 24
(2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an 25
additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other 26
penalty when obtaining clinician-administered drugs from a health care provider authorized under 27
the laws of this state to administer clinician-administered drugs, or a pharmacy; 28
(3) Shall not interfere with the patient's right to choose to obtain a clinician-administered 29
drug from their provider or pharmacy of choice, including inducement, steering, or offering 30
financial or other incentives; 31
(4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected 32
by the health plan or create such a requirement through contract with a third party, including, but 33
not limited to, a pharmacy benefit manager; 34
LC002496 - Page 5 of 8
(5) Shall not limit or exclude coverage for a clinician-administered drug when not 1
dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered; 2
(6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a 3
pharmacy not selected by the health plan or create such an arrangement through contract with a 4
third party, including, but not limited to, a pharmacy benefit manager; 5
(7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to 6
a participating provider for providing covered clinician-administered drugs and related services to 7
covered persons when all criteria for medical necessity are met, because the participating provider 8
obtains clinician-administered drugs from a pharmacy that is not a participating provider in the 9
health benefit issuer's network; 10
(8) Shall not require that an enrollee pay an additional fee, higher copay, higher 11
coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-12
administered drugs when not dispensed by a pharmacy selected by the health plan or create such a 13
requirement through contract with a third party, including, but not limited to, a pharmacy benefit 14
manager; 15
(9) Shall not require a specialty pharmacy to dispense a clinician-administered medication 16
directly to a patient with the intention that the patient will transport the medication to a healthcare 17
provider for administration. 18
(c) A health benefit issuer may offer, but shall not require, either directly or through 19
contract with a third party, including, but not limited to, a pharmacy benefit manager: 20
(1) The use of a home infusion pharmacy to dispense clinician-administered drugs to 21
patients in their homes or; 22
(2) The use of an infusion site external to a patient's provider office or clinic. 23
SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 24
Organizations" is hereby amended by adding thereto the following section: 25
27-41-38.3. Patient choice in dispensing of clinician-administered drugs. 26
(a) As used in this section: 27
(1) "Clinician-administered drug" means an outpatient prescription drug other than a 28
vaccine that: 29
(i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed 30
or by an individual assisting the patient with the self-administration; and 31
(ii) Is typically administered: 32
(A) By a health care provider authorized under the laws of this state to administer the drug, 33
including when acting under a physician's delegation and supervision; and 34
LC002496 - Page 6 of 8
(B) In a physician's office, hospital outpatient infusion center, or other clinical setting. 1
(b) A health benefit issuer or pharmacy benefit manager: 2
(1) Shall not refuse to authorize, approve, or pay a participating provider for providing 3
covered clinician-administered drugs and related services to covered persons; 4
(2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an 5
additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other 6
penalty when obtaining clinician-administered drugs from a health care provider authorized under 7
the laws of this state to administer clinician-administered drugs, or a pharmacy; 8
(3) Shall not interfere with the patient's right to choose to obtain a clinician-administered 9
drug from their provider or pharmacy of choice, including inducement, steering, or offering 10
financial or other incentives; 11
(4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected 12
by the health plan or create such a requirement through contract with a third party, including, but 13
not limited to, a pharmacy benefit manager; 14
(5) Shall not limit or exclude coverage for a clinician-administered drug when not 15
dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered; 16
(6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a 17
pharmacy not selected by the health plan or create such an arrangement through contract with a 18
third party, including, but not limited to, a pharmacy benefit manager; 19
(7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to 20
a participating provider for providing covered clinician-administered drugs and related services to 21
covered persons when all criteria for medical necessity are met, because the participating provider 22
obtains clinician-administered drugs from a pharmacy that is not a participating provider in the 23
health benefit issuer's network; 24
(8) Shall not require that an enrollee pay an additional fee, higher copay, higher 25
coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-26
administered drugs when not dispensed by a pharmacy selected by the health plan or create such a 27
requirement through contract with a third party, including, but not limited to, a pharmacy benefit 28
manager; 29
(9) Shall not require a specialty pharmacy to dispense a clinician-administered medication 30
directly to a patient with the intention that the patient will transport the medication to a healthcare 31
provider for administration. 32
(c) A health benefit issuer may offer, but shall not require, either directly or through 33
contract with a third party, including, but not limited to, a pharmacy benefit manager: 34
LC002496 - Page 7 of 8
(1) The use of a home infusion pharmacy to dispense clinician-administered drugs to 1
patients in their homes or; 2
(2) The use of an infusion site external to a patient's provider office or clinic. 3
SECTION 5. This act shall take effect upon passage. 4
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LC002496
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LC002496 - Page 8 of 8
EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
***
This act would prevent healthcare entities from refusing to authorize, approve, or pay a 1
participating provider for providing covered clinician-administered drugs and related services to 2
covered persons. This act would also prevent healthcare entities from imposing coverage or benefits 3
limitations, or require an enrollee to pay an additional fee, higher copay, higher coinsurance, second 4
copay, second coinsurance, or other penalty when obtaining clinician-administered drugs from a 5
health care provider. It would prohibit interference with the patient's right to choose to obtain a 6
clinician-administered drug from their provider or pharmacy of choice. 7
This act would take effect upon passage. 8
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LC002496
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