2025 -- S 0786
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LC002368
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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. 2025
____________
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
Introduced By: Senators Bissaillon, Lawson, Murray, DiMario, and Appollonio
Date Introduced: March 14, 2025
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
27-18-95. Prohibition of prior authorization or step therapy protocol. 3
(a) On and after January 1, 2026, every individual or group health insurance contract, or 4
every individual or group hospital or medical expense insurance policy, plan, or group policy 5
delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 6
therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 7
or antipsychotic on their drug formulary; if: 8
(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 9
medication classified as an anticonvulsant or antipsychotic; 10
(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 11
by the enrollee and has failed to produce the desired health outcomes; 12
(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 13
antipsychotic and has experienced unacceptable side effects; 14
(4) The enrollee has been stabilized on a nonpreferred medication classified as an 15
anticonvulsant or antipsychotic and transition to the preferred medication would be medically 16
contraindicated. 17
(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 18
classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 19
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(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 1
nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 2
health care provider in an inpatient setting. 3
(b) The provisions of subsection (a) of this section does not affect clinical prior 4
authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 5
(c) This section does prevent an individual or group health insurance contract, an individual 6
or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 7
delivery, or renewed in this state from denying an exception for a medication that has been removed 8
from the market due to safety concerns from the federal food and drug administration. 9
(d) For the purposes of this section, “step therapy protocol” means a protocol that 10
establishes a specific sequence in which prescription medications for a specified medical condition 11
are medically necessary for a particular enrollee and are covered under a pharmacy or medical 12
benefit by a carrier, including self-administered and physician-administered drugs. 13
SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service 14
Corporations" is hereby amended by adding thereto the following section: 15
27-19-87. Prohibition of prior authorization or step therapy protocol. 16
(a) On and after January 1, 2026, every individual or group health insurance contract, or 17
every individual or group hospital or medical expense insurance policy, plan, or group policy 18
delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 19
therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 20
or antipsychotic on their drug formulary; if: 21
(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 22
medication classified as an anticonvulsant or antipsychotic; 23
(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 24
by the enrollee and has failed to produce the desired health outcomes; 25
(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 26
antipsychotic and has experienced unacceptable side effects; 27
(4) The enrollee has been stabilized on a nonpreferred medication classified as an 28
anticonvulsant or antipsychotic and transition to the preferred medication would be medically 29
contraindicated. 30
(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 31
classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 32
(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 33
nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 34
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health care provider in an inpatient setting. 1
(b) The provisions of subsection (a) of this section does not affect clinical prior 2
authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 3
(c) This section does prevent an individual or group health insurance contract, an individual 4
or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 5
delivery, or renewed in this state from denying an exception for a medication that has been removed 6
from the market due to safety concerns from the federal food and drug administration. 7
(d) For the purposes of this section, “step therapy protocol” means a protocol that 8
establishes a specific sequence in which prescription medications for a specified medical condition 9
are medically necessary for a particular enrollee and are covered under a pharmacy or medical 10
benefit by a carrier, including self-administered and physician-administered drugs. 11
SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service 12
Corporations" is hereby amended by adding thereto the following section: 13
27-20-83. Prohibition of prior authorization or step therapy protocol. 14
(a) On and after January 1, 2026, every individual or group health insurance contract, or 15
every individual or group hospital or medical expense insurance policy, plan, or group policy 16
delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 17
therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 18
or antipsychotic on their drug formulary; if: 19
(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 20
medication classified as an anticonvulsant or antipsychotic; 21
(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 22
by the enrollee and has failed to produce the desired health outcomes; 23
(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 24
antipsychotic and has experienced unacceptable side effects; 25
(4) The enrollee has been stabilized on a nonpreferred medication classified as an 26
anticonvulsant or antipsychotic and transition to the preferred medication would be medically 27
contraindicated. 28
(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 29
classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 30
(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 31
nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 32
health care provider in an inpatient setting. 33
(b) The provisions of subsection (a) of this section does not affect clinical prior 34
LC002368 - Page 4 of 7
authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 1
(c) This section does prevent an individual or group health insurance contract, an individual 2
or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 3
delivery, or renewed in this state from denying an exception for a medication that has been removed 4
from the market due to safety concerns from the federal food and drug administration. 5
(d) For the purposes of this section, “step therapy protocol” means a protocol that 6
establishes a specific sequence in which prescription medications for a specified medical condition 7
are medically necessary for a particular enrollee and are covered under a pharmacy or medical 8
benefit by a carrier, including self-administered and physician-administered drugs. 9
SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance 10
Organizations" is hereby amended by adding thereto the following section: 11
27-41-100. Prohibition of prior authorization or step therapy protocol. 12
(a) On and after January 1, 2026, every individual or group health insurance contract, or 13
every individual or group hospital or medical expense insurance policy, plan, or group policy 14
delivered, issued for delivery, or renewed in this state shall not require prior authorization or a step 15
therapy protocol for the prescription of a nonpreferred medication classified as an anticonvulsant 16
or antipsychotic on their drug formulary; if: 17
(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 18
medication classified as an anticonvulsant or antipsychotic; 19
(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 20
by the enrollee and has failed to produce the desired health outcomes; 21
(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 22
antipsychotic and has experienced unacceptable side effects; 23
(4) The enrollee has been stabilized on a nonpreferred medication classified as an 24
anticonvulsant or antipsychotic and transition to the preferred medication would be medically 25
contraindicated. 26
(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 27
classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 28
(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 29
nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 30
health care provider in an inpatient setting. 31
(b) The provisions of subsection (a) of this section does not affect clinical prior 32
authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 33
(c) This section does prevent an individual or group health insurance contract, an individual 34
LC002368 - Page 5 of 7
or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for 1
delivery, or renewed in this state from denying an exception for a medication that has been removed 2
from the market due to safety concerns from the federal food and drug administration. 3
(d) For the purposes of this section, “step therapy protocol” means a protocol that 4
establishes a specific sequence in which prescription medications for a specified medical condition 5
are medically necessary for a particular enrollee and are covered under a pharmacy or medical 6
benefit by a carrier, including self-administered and physician-administered drugs. 7
SECTION 5. Chapter 40-21 of the General Laws entitled "Medical Assistance — 8
Prescription Drugs" is hereby amended by adding thereto the following section: 9
40-21-4. Prohibition of prior authorization or step therapy protocol. 10
(a) On and after January 1, 2026, the Rhode Island medical assistance program, as defined 11
by this chapter, and any contract between the Rhode Island medical assistance program, as defined 12
under chapter 8 of title 40, and a managed care organization shall not require prior authorization or 13
a step therapy protocol for the prescription of a nonpreferred medication classified as an 14
anticonvulsant or antipsychotic on their drug formulary if: 15
(1) The enrollee has been previously prescribed and filled or refilled a nonpreferred 16
medication classified as an anticonvulsant or antipsychotic; 17
(2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried 18
by the enrollee and has failed to produce the desired health outcomes; 19
(3) The enrollee has tried a preferred mediation classified as an anticonvulsant or 20
antipsychotic and has experienced unacceptable side effects; 21
(4) The enrollee has been stabilized on a nonpreferred medication classified as an 22
anticonvulsant or antipsychotic and transition to the preferred medication would be medically 23
contraindicated. 24
(5) The enrollee was prescribed and unsuccessfully treated with a preferred medication 25
classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or 26
(6) Upon confirmation of the enrollee's inpatient utilization, the enrollee is stable on a 27
nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their 28
health care provider in an inpatient setting. 29
(b) If the secretary of health and human services determines that authorization from a 30
federal agency is necessary for the implementation of this section, the executive office of health 31
and human services is authorized to seek such state plan amendment and may delay implementing 32
the provisions until the authorization is granted. 33
(c) The Rhode Island medical assistance program, as defined under chapter 8 of title 40, 34
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shall require, through amending current and future medical assistance managed care contracts, that 1
the managed care organizations meet the provisions of this section. 2
(d) The provisions of subsection (a) of this section does not affect clinical prior 3
authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic. 4
(e) This section does prevent the Rhode Island medical assistance program, as defined 5
under chapter 8 of title 40, and any contract between the Rhode Island medical assistance program 6
and a managed care organization from denying an exception for a medication that has been removed 7
from the market due to safety concerns from the federal food and drug administration. 8
(f) For the purposes of this section, "step therapy protocol" means a protocol that 9
establishes a specific sequence in which prescription medications for a specified medical condition 10
are medically necessary for a particular enrollee and are covered under a pharmacy or medical 11
benefit by a carrier, including self-administered and physician-administered drugs. 12
SECTION 6. This act shall take effect upon passage. 13
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES
***
This act would prohibit the Rhode Island medical assistance program, and any contract 1
between the Rhode Island medical assistance program and a managed care organization from 2
requiring prior authorization or a step therapy protocol for the prescription of a nonpreferred 3
medication on their drug formulary used to assess or treat an enrollee's bipolar disorder, 4
schizophrenia or schizotypal disorder, major depressive disorder, or post-traumatic stress disorder 5
as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental 6
Disorders, fifth edition, or epilepsy or seizure disorder under certain circumstances. 7
This act would take effect upon passage. 8
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LC002368
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