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5 | 5 | | 2025 -- H 6209 |
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6 | 6 | | ======== |
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7 | 7 | | LC002656 |
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8 | 8 | | ======== |
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9 | 9 | | S T A T E O F R H O D E I S L A N D |
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10 | 10 | | IN GENERAL ASSEMBLY |
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11 | 11 | | JANUARY SESSION, A.D. 2025 |
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12 | 12 | | ____________ |
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13 | 13 | | |
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14 | 14 | | A N A C T |
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15 | 15 | | RELATING TO INSURANCE -- PRESCRIPTION DRUG BENEFITS |
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16 | 16 | | Introduced By: Representatives Furtado, Kazarian, Stewart, Voas, Handy, Dawson, |
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17 | 17 | | Boylan, Speakman, Bennett, and Messier |
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18 | 18 | | Date Introduced: April 09, 2025 |
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19 | 19 | | Referred To: House Health & Human Services |
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20 | 20 | | |
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21 | 21 | | |
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22 | 22 | | It is enacted by the General Assembly as follows: |
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23 | 23 | | SECTION 1. Section 27-20.8-1 of the General Laws in Chapter 27-20.8 entitled 1 |
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24 | 24 | | "Prescription Drug Benefits" is hereby amended to read as follows: 2 |
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25 | 25 | | 27-20.8-1. Definitions. 3 |
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26 | 26 | | For the purposes of this chapter, the following terms shall mean: 4 |
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27 | 27 | | (1) “Cost sharing” shall mean any copayment, coinsurance, deductible, or annual limitation 5 |
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28 | 28 | | on cost sharing (including, but not limited to, a limitation subject to 42 U.S.C. §§ 18022(c) and 6 |
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29 | 29 | | 300gg-6(b)), required by or on behalf of an enrollee in order to receive a specific health care service, 7 |
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30 | 30 | | including a prescription drug, covered by a health plan, whether covered under the medical or 8 |
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31 | 31 | | pharmacy benefit. 9 |
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32 | 32 | | (1)(2) “Director” shall mean the director of the department of business regulation. 10 |
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33 | 33 | | (2)(3) “Health plan” shall mean an insurance carrier as defined in chapters 18, 19, 20, and 11 |
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34 | 34 | | 41 of this title. 12 |
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35 | 35 | | (3)(4) “Insured” shall mean any person who is entitled to have pharmacy services paid by 13 |
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36 | 36 | | a health plan pursuant to a policy, certificate, contract, or agreement of insurance or coverage 14 |
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37 | 37 | | including those administered for the health plan under a contract with a third-party administrator 15 |
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38 | 38 | | that manages pharmacy benefits or pharmacy network contracts. 16 |
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39 | 39 | | (5) “Insurer” shall mean any person, firm, or corporation offering and/or insuring 17 |
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40 | 40 | | healthcare services on a prepaid basis, including, but not limited to, a nonprofit service corporation, 18 |
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41 | 41 | | a health maintenance organization, the Rhode Island Medicaid program, including its contracted 19 |
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42 | 42 | | |
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43 | 43 | | |
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44 | 44 | | LC002656 - Page 2 of 4 |
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45 | 45 | | managed care entities, or an entity offering a policy of accident and sickness insurance. 1 |
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46 | 46 | | (6) “Person” shall mean a natural person, corporation, mutual company, unincorporated 2 |
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47 | 47 | | association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit 3 |
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48 | 48 | | corporation, unincorporated organization, or government or governmental subdivision or agency. 4 |
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49 | 49 | | (7) “Pharmacy benefit manager” shall mean any person or business who administers the 5 |
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50 | 50 | | prescription drug or device program of one or more health plans on behalf of a third party in 6 |
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51 | 51 | | accordance with a pharmacy benefit program. This term includes any agent or representative of a 7 |
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52 | 52 | | pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the 8 |
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53 | 53 | | administering of the drug program and any wholly or partially owned or controlled subsidiary of a 9 |
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54 | 54 | | pharmacy benefit manager. 10 |
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55 | 55 | | SECTION 2. Chapter 27-20.8 of the General Laws entitled "Prescription Drug Benefits" is 11 |
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56 | 56 | | hereby amended by adding thereto the following section: 12 |
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57 | 57 | | 27-20.8-5. Cost sharing calculation. 13 |
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58 | 58 | | (a) When calculating an enrollee’s overall contribution to any out-of-pocket maximum or 14 |
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59 | 59 | | any cost sharing requirement under a health plan, an insurer or pharmacy benefit manager shall 15 |
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60 | 60 | | include any amounts paid by the enrollee or paid on behalf of the enrollee by another person that 16 |
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61 | 61 | | is either: 17 |
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62 | 62 | | (1) Without a generic equivalent; or 18 |
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63 | 63 | | (2) With a generic equivalent where the enrollee has obtained access to the prescription 19 |
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64 | 64 | | drug through any of the following: 20 |
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65 | 65 | | (i) Prior authorization; 21 |
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66 | 66 | | (ii) A step therapy protocol; 22 |
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67 | 67 | | (iii) The health care plan or carrier’s exceptions and appeals process. 23 |
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68 | 68 | | (b) If under federal law, application of subsection (a) of this section would result in Health 24 |
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69 | 69 | | Savings Account ineligibility under § 223 of the federal Internal Revenue Code, this requirement 25 |
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70 | 70 | | shall apply only for Health Savings Account qualified High Deductible Health Plans with respect 26 |
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71 | 71 | | to the deductible of such a plan after the enrollee has satisfied the minimum deductible under § 27 |
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72 | 72 | | 223, except for items or services that are preventive care pursuant to § 223(c)(2)(C) of the federal 28 |
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73 | 73 | | Internal Revenue Code, in which case the requirements of subsection (a) of this section shall apply 29 |
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74 | 74 | | regardless of satisfaction of the minimum deductible under § 223. 30 |
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75 | 75 | | (c) This section shall apply with respect to health plans that are entered into, amended, 31 |
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76 | 76 | | extended, or renewed on or after January 1, 2026. 32 |
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77 | 77 | | |
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78 | 78 | | |
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79 | 79 | | LC002656 - Page 3 of 4 |
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80 | 80 | | SECTION 3. This act shall take effect upon passage. 1 |
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81 | 81 | | ======== |
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82 | 82 | | LC002656 |
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84 | 84 | | |
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85 | 85 | | |
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86 | 86 | | LC002656 - Page 4 of 4 |
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87 | 87 | | EXPLANATION |
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88 | 88 | | BY THE LEGISLATIVE COUNCIL |
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89 | 89 | | OF |
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90 | 90 | | A N A C T |
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91 | 91 | | RELATING TO INSURANCE -- PRESCRIPTION DRUG BENEFITS |
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92 | 92 | | *** |
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93 | 93 | | This act would include any costs paid by an enrollee or on behalf of the enrollee by a third 1 |
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94 | 94 | | party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost 2 |
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95 | 95 | | sharing requirement under a health plan as of January 1, 2026. 3 |
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96 | 96 | | This act would take effect upon passage. 4 |
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97 | 97 | | ======== |
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98 | 98 | | LC002656 |
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