Rhode Island 2025 Regular Session

Rhode Island Senate Bill S0786 Compare Versions

Only one version of the bill is available at this time.

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5	5	2025 -- S 0786
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7	7	LC002368
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9	9	S T A T E O F R H O D E I S L A N D
10	10	IN GENERAL ASSEMBLY
11	11	JANUARY SESSION, A.D. 2025
12	12	____________
13	13
14	14	A N A C T
15	15	RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
16	16	Introduced By: Senators Bissaillon, Lawson, Murray, DiMario, and Appollonio
17	17	Date Introduced: March 14, 2025
18	18	Referred To: Senate Health & Human Services
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20	20
21	21	It is enacted by the General Assembly as follows:
22	22	SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance 1
23	23	Policies" is hereby amended by adding thereto the following section: 2
24	24	27-18-95. Prohibition of prior authorization or step therapy protocol. 3
25	25	(a) On and after January 1, 2026, every individual or group health insurance contract, or 4
26	26	every individual or group hospital or medical expense insurance policy, plan, or group policy 5
27	27	delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 6
28	28	therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 7
29	29	or antipsychotic on their drug formulary; if: 8
30	30	(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 9
31	31	medication classified as an anticonvulsant or antipsychotic; 10
32	32	(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 11
33	33	by the enrollee and has failed to produce the desired health outcomes; 12
34	34	(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 13
35	35	antipsychotic and has experienced unacceptable side effects; 14
36	36	(4) The enrollee has been stabilized on a nonpreferred medication classified as an 15
37	37	anticonvulsant or antipsychotic and transition to the preferred medication would be medically 16
38	38	contraindicated. 17
39	39	(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 18
40	40	classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 19
41	41
42	42
43	43	LC002368 - Page 2 of 7
44	44	(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 1
45	45	nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 2
46	46	health care provider in an inpatient setting. 3
47	47	(b) The provisions of subsection (a) of this section does not affect clinical prior 4
48	48	authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 5
49	49	(c) This section does prevent an individual or group health insurance contract, an individual 6
50	50	or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 7
51	51	delivery, or renewed in this state from denying an exception for a medication that has been removed 8
52	52	from the market due to safety concerns from the federal food and drug administration. 9
53	53	(d) For the purposes of this section, “step therapy protocol” means a protocol that 10
54	54	establishes a specific sequence in which prescription medications for a specified medical condition 11
55	55	are medically necessary for a particular enrollee and are covered under a pharmacy or medical 12
56	56	benefit by a carrier, including self-administered and physician-administered drugs. 13
57	57	SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 14
58	58	Corporations" is hereby amended by adding thereto the following section: 15
59	59	27-19-87. Prohibition of prior authorization or step therapy protocol. 16
60	60	(a) On and after January 1, 2026, every individual or group health insurance contract, or 17
61	61	every individual or group hospital or medical expense insurance policy, plan, or group policy 18
62	62	delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 19
63	63	therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 20
64	64	or antipsychotic on their drug formulary; if: 21
65	65	(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 22
66	66	medication classified as an anticonvulsant or antipsychotic; 23
67	67	(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 24
68	68	by the enrollee and has failed to produce the desired health outcomes; 25
69	69	(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 26
70	70	antipsychotic and has experienced unacceptable side effects; 27
71	71	(4) The enrollee has been stabilized on a nonpreferred medication classified as an 28
72	72	anticonvulsant or antipsychotic and transition to the preferred medication would be medically 29
73	73	contraindicated. 30
74	74	(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 31
75	75	classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 32
76	76	(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 33
77	77	nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 34
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79	79
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81	81	health care provider in an inpatient setting. 1
82	82	(b) The provisions of subsection (a) of this section does not affect clinical prior 2
83	83	authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 3
84	84	(c) This section does prevent an individual or group health insurance contract, an individual 4
85	85	or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 5
86	86	delivery, or renewed in this state from denying an exception for a medication that has been removed 6
87	87	from the market due to safety concerns from the federal food and drug administration. 7
88	88	(d) For the purposes of this section, “step therapy protocol” means a protocol that 8
89	89	establishes a specific sequence in which prescription medications for a specified medical condition 9
90	90	are medically necessary for a particular enrollee and are covered under a pharmacy or medical 10
91	91	benefit by a carrier, including self-administered and physician-administered drugs. 11
92	92	SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 12
93	93	Corporations" is hereby amended by adding thereto the following section: 13
94	94	27-20-83. Prohibition of prior authorization or step therapy protocol. 14
95	95	(a) On and after January 1, 2026, every individual or group health insurance contract, or 15
96	96	every individual or group hospital or medical expense insurance policy, plan, or group policy 16
97	97	delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 17
98	98	therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 18
99	99	or antipsychotic on their drug formulary; if: 19
100	100	(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 20
101	101	medication classified as an anticonvulsant or antipsychotic; 21
102	102	(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 22
103	103	by the enrollee and has failed to produce the desired health outcomes; 23
104	104	(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 24
105	105	antipsychotic and has experienced unacceptable side effects; 25
106	106	(4) The enrollee has been stabilized on a nonpreferred medication classified as an 26
107	107	anticonvulsant or antipsychotic and transition to the preferred medication would be medically 27
108	108	contraindicated. 28
109	109	(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 29
110	110	classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 30
111	111	(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 31
112	112	nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 32
113	113	health care provider in an inpatient setting. 33
114	114	(b) The provisions of subsection (a) of this section does not affect clinical prior 34
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116	116
117	117	LC002368 - Page 4 of 7
118	118	authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 1
119	119	(c) This section does prevent an individual or group health insurance contract, an individual 2
120	120	or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 3
121	121	delivery, or renewed in this state from denying an exception for a medication that has been removed 4
122	122	from the market due to safety concerns from the federal food and drug administration. 5
123	123	(d) For the purposes of this section, “step therapy protocol” means a protocol that 6
124	124	establishes a specific sequence in which prescription medications for a specified medical condition 7
125	125	are medically necessary for a particular enrollee and are covered under a pharmacy or medical 8
126	126	benefit by a carrier, including self-administered and physician-administered drugs. 9
127	127	SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 10
128	128	Organizations" is hereby amended by adding thereto the following section: 11
129	129	27-41-100. Prohibition of prior authorization or step therapy protocol. 12
130	130	(a) On and after January 1, 2026, every individual or group health insurance contract, or 13
131	131	every individual or group hospital or medical expense insurance policy, plan, or group policy 14
132	132	delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 15
133	133	therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 16
134	134	or antipsychotic on their drug formulary; if: 17
135	135	(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 18
136	136	medication classified as an anticonvulsant or antipsychotic; 19
137	137	(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 20
138	138	by the enrollee and has failed to produce the desired health outcomes; 21
139	139	(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 22
140	140	antipsychotic and has experienced unacceptable side effects; 23
141	141	(4) The enrollee has been stabilized on a nonpreferred medication classified as an 24
142	142	anticonvulsant or antipsychotic and transition to the preferred medication would be medically 25
143	143	contraindicated. 26
144	144	(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 27
145	145	classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 28
146	146	(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 29
147	147	nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 30
148	148	health care provider in an inpatient setting. 31
149	149	(b) The provisions of subsection (a) of this section does not affect clinical prior 32
150	150	authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 33
151	151	(c) This section does prevent an individual or group health insurance contract, an individual 34
152	152
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154	154	LC002368 - Page 5 of 7
155	155	or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 1
156	156	delivery, or renewed in this state from denying an exception for a medication that has been removed 2
157	157	from the market due to safety concerns from the federal food and drug administration. 3
158	158	(d) For the purposes of this section, “step therapy protocol” means a protocol that 4
159	159	establishes a specific sequence in which prescription medications for a specified medical condition 5
160	160	are medically necessary for a particular enrollee and are covered under a pharmacy or medical 6
161	161	benefit by a carrier, including self-administered and physician-administered drugs. 7
162	162	SECTION 5. Chapter 40-21 of the General Laws entitled "Medical Assistance — 8
163	163	Prescription Drugs" is hereby amended by adding thereto the following section: 9
164	164	40-21-4. Prohibition of prior authorization or step therapy protocol. 10
165	165	(a) On and after January 1, 2026, the Rhode Island medical assistance program, as defined 11
166	166	by this chapter, and any contract between the Rhode Island medical assistance program, as defined 12
167	167	under chapter 8 of title 40, and a managed care organization shall not require prior authorization or 13
168	168	a step therapy protocol for the prescription of a nonpreferred medication classified as an 14
169	169	anticonvulsant or antipsychotic on their drug formulary if: 15
170	170	(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 16
171	171	medication classified as an anticonvulsant or antipsychotic; 17
172	172	(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 18
173	173	by the enrollee and has failed to produce the desired health outcomes; 19
174	174	(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 20
175	175	antipsychotic and has experienced unacceptable side effects; 21
176	176	(4) The enrollee has been stabilized on a nonpreferred medication classified as an 22
177	177	anticonvulsant or antipsychotic and transition to the preferred medication would be medically 23
178	178	contraindicated. 24
179	179	(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 25
180	180	classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 26
181	181	(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 27
182	182	nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 28
183	183	health care provider in an inpatient setting. 29
184	184	(b) If the secretary of health and human services determines that authorization from a 30
185	185	federal agency is necessary for the implementation of this section, the executive office of health 31
186	186	and human services is authorized to seek such state plan amendment and may delay implementing 32
187	187	the provisions until the authorization is granted. 33
188	188	(c) The Rhode Island medical assistance program, as defined under chapter 8 of title 40, 34
189	189
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192	192	shall require, through amending current and future medical assistance managed care contracts, that 1
193	193	the managed care organizations meet the provisions of this section. 2
194	194	(d) The provisions of subsection (a) of this section does not affect clinical prior 3
195	195	authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 4
196	196	(e) This section does prevent the Rhode Island medical assistance program, as defined 5
197	197	under chapter 8 of title 40, and any contract between the Rhode Island medical assistance program 6
198	198	and a managed care organization from denying an exception for a medication that has been removed 7
199	199	from the market due to safety concerns from the federal food and drug administration. 8
200	200	(f) For the purposes of this section, "step therapy protocol" means a protocol that 9
201	201	establishes a specific sequence in which prescription medications for a specified medical condition 10
202	202	are medically necessary for a particular enrollee and are covered under a pharmacy or medical 11
203	203	benefit by a carrier, including self-administered and physician-administered drugs. 12
204	204	SECTION 6. This act shall take effect upon passage. 13
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211	211	EXPLANATION
212	212	BY THE LEGISLATIVE COUNCIL
213	213	OF
214	214	A N A C T
215	215	RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
216	216	***
217	217	This act would prohibit the Rhode Island medical assistance program, and any contract 1
218	218	between the Rhode Island medical assistance program and a managed care organization from 2
219	219	requiring prior authorization or a step therapy protocol for the prescription of a nonpreferred 3
220	220	medication on their drug formulary used to assess or treat an enrollee's bipolar disorder, 4
221	221	schizophrenia or schizotypal disorder, major depressive disorder, or post-traumatic stress disorder 5
222	222	as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental 6
223	223	Disorders, fifth edition, or epilepsy or seizure disorder under certain circumstances. 7
224	224	This act would take effect upon passage. 8
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