2023 -- S 0871
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LC001490
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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
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A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
Introduced By: Senators Goodwin, Lombardo, and Ruggerio
Date Introduced: March 30, 2023
Referred To: Senate Health & Human Services
It is enacted by the General Assembly as follows:
SECTION 1. Legislative findings. 1
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
SECTION 2. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance 13
Policies" is hereby amended by adding thereto the following section: 14
27-18-50.2. Specialty drugs. 15
(a) As used in this section, the following words shall have the following meanings: 16
(1) "Complex or chronic medical condition" means a physical, behavioral, or 17
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 18
advances over time, and: 19
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(i) May have no known cure; 1
(ii) Is progressive; or 2
(iii) Can be debilitating or fatal if left untreated or undertreated. 3
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 4
hepatitis c, and rheumatoid arthritis. 5
(2) "Pre-service authorization" means a cost containment method that an insurer, a 6
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 7
coverage for drugs prescribed by a health care provider for a covered individual to control 8
utilization, quality, and claims. 9
(3) "Rare medical condition" means a disease or condition that affects fewer than: 10
(i) Two hundred thousand (200,000) individuals in the United States; or 11
(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 12
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 13
multiple myeloma. 14
(4) "Specialty drug" means a prescription drug that: 15
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 16
medical condition; and 17
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 18
specialty tier threshold, as updated from time to time. 19
(b) Every individual or group health insurance contract, plan or policy that provides 20
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 21
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 22
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 23
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 24
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 25
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 26
(c) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 27
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 28
fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 29
(d) The health insurance commissioner may promulgate any rules and regulations 30
necessary to implement and administer this section in accordance with any federal requirements 31
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 32
this section. 33
SECTION 3. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 34
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Corporations" is hereby amended by adding thereto the following section: 1
27-19-42.1. Specialty drugs. 2
(a) As used in this section, the following words shall have the following meanings: 3
(1) "Complex or chronic medical condition" means a physical, behavioral, or 4
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 5
advances over time, and: 6
(i) May have no known cure; 7
(ii) Is progressive; or 8
(iii) Can be debilitating or fatal if left untreated or undertreated. 9
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 10
hepatitis c, and rheumatoid arthritis. 11
(2) "Pre-service authorization" means a cost containment method that an insurer, a 12
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 13
coverage for drugs prescribed by a health care provider for a covered individual to control 14
utilization, quality, and claims. 15
(3) "Rare medical condition" means a disease or condition that affects fewer than: 16
(i) Two hundred thousand (200,000) individuals in the United States; or 17
(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 18
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 19
multiple myeloma. 20
(4) "Specialty drug" means a prescription drug that: 21
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 22
medical condition; and 23
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 24
specialty tier threshold, as updated from time to time. 25
(b) Every individual or group health insurance contract, plan or policy that provides 26
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 27
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 28
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 29
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 30
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 31
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 32
(c) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 33
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 34
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fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 1
(d) The health insurance commissioner may promulgate any rules and regulations 2
necessary to implement and administer this section in accordance with any federal requirements 3
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 4
this section. 5
SECTION 4. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 6
Corporations" is hereby amended by adding thereto the following section: 7
27-20-37.1. Specialty drugs. 8
(a) As used in this section, the following words shall have the following meanings: 9
(1) "Complex or chronic medical condition" means a physical, behavioral, or 10
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 11
advances over time, and: 12
(i) May have no known cure; 13
(ii) Is progressive; or 14
(iii) Can be debilitating or fatal if left untreated or undertreated. 15
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 16
hepatitis c, and rheumatoid arthritis. 17
(2) "Pre-service authorization" means a cost containment method that an insurer, a 18
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 19
coverage for drugs prescribed by a health care provider for a covered individual to control 20
utilization, quality, and claims. 21
(3) "Rare medical condition" means a disease or condition that affects fewer than: 22
(i) Two hundred thousand (200,000) individuals in the United States; or 23
(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 24
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 25
multiple myeloma. 26
(4) "Specialty drug" means a prescription drug that: 27
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 28
medical condition; and 29
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 30
specialty tier threshold, as updated from time to time. 31
(iii) Is not typically stocked at retail pharmacies; and 32
(iv)(A) Requires a difficult or unusual process of delivery to the patient in the preparation, 33
handling, storage, inventory, or distribution of the drug; or 34
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(B) Requires enhanced patient education, management, or support, beyond those required 1
for traditional dispensing, before or after administration of the drug. 2
(b) Every individual or group health insurance contract, plan or policy that provides 3
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 4
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 5
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 6
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 7
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 8
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 9
(c) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 10
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 11
fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 12
(d) The health insurance commissioner may promulgate any rules and regulations 13
necessary to implement and administer this section in accordance with any federal requirements 14
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 15
this section. 16
SECTION 5. Chapter 27-41 of the General Laws entitled "Health Maintenance 17
Organizations" is hereby amended by adding thereto the following section: 18
27-41-38.3. Specialty drugs. 19
(a) As used in this section, the following words shall have the following meanings: 20
(1) "Complex or chronic medical condition" means a physical, behavioral, or 21
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that 22
advances over time, and: 23
(i) May have no known cure; 24
(ii) Is progressive; or 25
(iii) Can be debilitating or fatal if left untreated or undertreated. 26
"Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis, 27
hepatitis c, and rheumatoid arthritis. 28
(2) "Pre-service authorization" means a cost containment method that an insurer, a 29
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize 30
coverage for drugs prescribed by a health care provider for a covered individual to control 31
utilization, quality, and claims. 32
(3) "Rare medical condition" means a disease or condition that affects fewer than: 33
(i) Two hundred thousand (200,000) individuals in the United States; or 34
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(ii) Approximately one in one thousand five hundred (1,500) individuals worldwide. 1
"Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and 2
multiple myeloma. 3
(4) "Specialty drug" means a prescription drug that: 4
(i) Is prescribed for an individual with a complex or chronic medical condition or a rare 5
medical condition; and 6
(ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D 7
specialty tier threshold, as updated from time to time. 8
(b) Every individual or group health insurance contract, plan or policy that provides 9
prescription coverage and is delivered, issued for delivery or renewed in this state on or after 10
January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty 11
drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty 12
drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage 13
for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a 14
deductible requirement would cause a health plan to not qualify as a high deductible health plan. 15
(c) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit 16
medical plan from reducing a covered individual's cost sharing to an amount less than one hundred 17
fifty dollars ($150) for a thirty (30)-day supply of a specialty drug. 18
(d) The health insurance commissioner may promulgate any rules and regulations 19
necessary to implement and administer this section in accordance with any federal requirements 20
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of 21
this section. 22
SECTION 6. This act shall take effect upon passage. 23
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
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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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LC001490
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