Rhode Island 2025 Regular Session

Rhode Island House Bill H6209 Compare Versions

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55 2025 -- H 6209
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99 S T A T E O F R H O D E I S L A N D
1010 IN GENERAL ASSEMBLY
1111 JANUARY SESSION, A.D. 2025
1212 ____________
1313
1414 A N A C T
1515 RELATING TO INSURANCE -- PRESCRIPTION DRUG BENEFITS
1616 Introduced By: Representatives Furtado, Kazarian, Stewart, Voas, Handy, Dawson,
1717 Boylan, Speakman, Bennett, and Messier
1818 Date Introduced: April 09, 2025
1919 Referred To: House Health & Human Services
2020
2121
2222 It is enacted by the General Assembly as follows:
2323 SECTION 1. Section 27-20.8-1 of the General Laws in Chapter 27-20.8 entitled 1
2424 "Prescription Drug Benefits" is hereby amended to read as follows: 2
2525 27-20.8-1. Definitions. 3
2626 For the purposes of this chapter, the following terms shall mean: 4
2727 (1) “Cost sharing” shall mean any copayment, coinsurance, deductible, or annual limitation 5
2828 on cost sharing (including, but not limited to, a limitation subject to 42 U.S.C. §§ 18022(c) and 6
2929 300gg-6(b)), required by or on behalf of an enrollee in order to receive a specific health care service, 7
3030 including a prescription drug, covered by a health plan, whether covered under the medical or 8
3131 pharmacy benefit. 9
3232 (1)(2) “Director” shall mean the director of the department of business regulation. 10
3333 (2)(3) “Health plan” shall mean an insurance carrier as defined in chapters 18, 19, 20, and 11
3434 41 of this title. 12
3535 (3)(4) “Insured” shall mean any person who is entitled to have pharmacy services paid by 13
3636 a health plan pursuant to a policy, certificate, contract, or agreement of insurance or coverage 14
3737 including those administered for the health plan under a contract with a third-party administrator 15
3838 that manages pharmacy benefits or pharmacy network contracts. 16
3939 (5) “Insurer” shall mean any person, firm, or corporation offering and/or insuring 17
4040 healthcare services on a prepaid basis, including, but not limited to, a nonprofit service corporation, 18
4141 a health maintenance organization, the Rhode Island Medicaid program, including its contracted 19
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4545 managed care entities, or an entity offering a policy of accident and sickness insurance. 1
4646 (6) “Person” shall mean a natural person, corporation, mutual company, unincorporated 2
4747 association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit 3
4848 corporation, unincorporated organization, or government or governmental subdivision or agency. 4
4949 (7) “Pharmacy benefit manager” shall mean any person or business who administers the 5
5050 prescription drug or device program of one or more health plans on behalf of a third party in 6
5151 accordance with a pharmacy benefit program. This term includes any agent or representative of a 7
5252 pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the 8
5353 administering of the drug program and any wholly or partially owned or controlled subsidiary of a 9
5454 pharmacy benefit manager. 10
5555 SECTION 2. Chapter 27-20.8 of the General Laws entitled "Prescription Drug Benefits" is 11
5656 hereby amended by adding thereto the following section: 12
5757 27-20.8-5. Cost sharing calculation. 13
5858 (a) When calculating an enrollee’s overall contribution to any out-of-pocket maximum or 14
5959 any cost sharing requirement under a health plan, an insurer or pharmacy benefit manager shall 15
6060 include any amounts paid by the enrollee or paid on behalf of the enrollee by another person that 16
6161 is either: 17
6262 (1) Without a generic equivalent; or 18
6363 (2) With a generic equivalent where the enrollee has obtained access to the prescription 19
6464 drug through any of the following: 20
6565 (i) Prior authorization; 21
6666 (ii) A step therapy protocol; 22
6767 (iii) The health care plan or carrier’s exceptions and appeals process. 23
6868 (b) If under federal law, application of subsection (a) of this section would result in Health 24
6969 Savings Account ineligibility under § 223 of the federal Internal Revenue Code, this requirement 25
7070 shall apply only for Health Savings Account qualified High Deductible Health Plans with respect 26
7171 to the deductible of such a plan after the enrollee has satisfied the minimum deductible under § 27
7272 223, except for items or services that are preventive care pursuant to § 223(c)(2)(C) of the federal 28
7373 Internal Revenue Code, in which case the requirements of subsection (a) of this section shall apply 29
7474 regardless of satisfaction of the minimum deductible under § 223. 30
7575 (c) This section shall apply with respect to health plans that are entered into, amended, 31
7676 extended, or renewed on or after January 1, 2026. 32
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8080 SECTION 3. This act shall take effect upon passage. 1
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8787 EXPLANATION
8888 BY THE LEGISLATIVE COUNCIL
8989 OF
9090 A N A C T
9191 RELATING TO INSURANCE -- PRESCRIPTION DRUG BENEFITS
9292 ***
9393 This act would include any costs paid by an enrollee or on behalf of the enrollee by a third 1
9494 party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost 2
9595 sharing requirement under a health plan as of January 1, 2026. 3
9696 This act would take effect upon passage. 4
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