Chapter 233
2023 -- S 0871 SUBSTITUTE A
Enacted 06/23/2023

A N   A C T
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

Introduced By: Senators Goodwin, Lombardo, Ruggerio, and Valverde

Date Introduced: March 30, 2023

It is enacted by the General Assembly as follows:
     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance
Policies" is hereby amended by adding thereto the following section:
     27-18-50.2. Specialty drugs.
     (a) The general assembly makes the following findings:
     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)
residents had two (2) or more chronic diseases, which significantly increases their likelihood to
depend on prescription specialty drugs;
     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a
prescription drug as prescribed due to cost;
     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to
create competition and help lower their prices; and
     (4) In 2022, the Centers for Medicare and & Medicaid Services define any drug for which
the negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.
     (b) As used in this section, the following words shall have the following meanings:
     (1) "Complex or chronic medical condition" means a physical, behavioral, or
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that
advances over time, and:
     (i) May have no known cure;
     (ii) Is progressive; or
     (iii) Can be debilitating or fatal if left untreated or undertreated.
     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,
hepatitis c, and rheumatoid arthritis.
     (2) "Pre-service authorization" means a cost containment method that an insurer, a
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize
coverage for drugs prescribed by a health care healthcare provider for a covered individual to
control utilization, quality, and claims.
     (3) "Rare medical condition" means a disease or condition that affects fewer than:
     (i) Two hundred thousand (200,000) individuals in the United States; or
     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.
     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and
multiple myeloma.
     (4) "Specialty drug" means a prescription drug that exceeds the threshold for a specialty
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and
Modernization Act of 2003 (Public Law 108-173)).
     (5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a
cost-sharing obligation for a specialty drug.
     (c) Every individual or group health insurance contract, plan, or policy that provides
prescription drug coverage and is delivered, issued for delivery, or renewed in this state on or after
January 1, 2025, shall limit any required copayment of or coinsurance applicable to covered drugs
on a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for
each drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any
copayment or coinsurance. This limit shall be applicable after any deductible is reached and until
the individual's maximum out-of-pocket limit has been reached.
     (d) Nothing in this section shall prevent an entity subject to this section from reducing a
covered individual's cost sharing for a specialty drug to an amount less than that described in section
(c) of this section.
     (e) The health insurance commissioner may promulgate any rules and regulations
necessary to implement and administer this section in accordance with any federal requirements
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of
this section.
     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service
Corporations" is hereby amended by adding thereto the following section:
     27-19-42.1. Specialty drugs.
     (a) The general assembly makes the following findings:
     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)
residents had two (2) or more chronic diseases, which significantly increases their likelihood to
depend on prescription specialty drugs;
     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a
prescription drug as prescribed due to cost;
     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to
create competition and help lower their prices; and
     (4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the
negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.
     (b) As used in this section, the following words shall have the following meanings:
     (1) "Complex or chronic medical condition" means a physical, behavioral, or
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that
advances over time, and:
     (i) May have no known cure;
     (ii) Is progressive; or
     (iii) Can be debilitating or fatal if left untreated or undertreated.
     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,
hepatitis c, and rheumatoid arthritis.
     (2) "Pre-service authorization" means a cost containment method that an insurer, a
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize
coverage for drugs prescribed by a health care healthcare provider for a covered individual to
control utilization, quality, and claims.
     (3) "Rare medical condition" means a disease or condition that affects fewer than:
     (i) Two hundred thousand (200,000) individuals in the United States; or
     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.
     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and
multiple myeloma.
     (4) "Specialty drug" means a prescription drug that exceeds the threshold for a specialty
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and
Modernization Act of 2003 (Public Law 108-173)).
     (5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a
cost-sharing obligation for a specialty drug.
     (c) Every individual or group health insurance contract, plan, or policy that provides
prescription drug coverage and is delivered, issued for delivery, or renewed in this state on or after
January 1, 2025, shall limit any required copayment of or coinsurance applicable to covered drugs
on a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for
each drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any
copayment or coinsurance. This limit shall be applicable after any deductible is reached and until
the individual's maximum out-of-pocket limit has been reached.
     (d) Nothing in this section shall prevent an entity subject to this section from reducing a
covered individual's cost sharing for a specialty drug to an amount less than that described in section
subsection (c) of this section.
     (e) The health insurance commissioner may promulgate any rules and regulations
necessary to implement and administer this section in accordance with any federal requirements
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of
this section.
     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service
Corporations" is hereby amended by adding thereto the following section:
     27-20-37.1. Specialty drugs.
     (a) The general assembly makes the following findings:
     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)
residents had two (2) or more chronic diseases, which significantly increases their likelihood to
depend on prescription specialty drugs;
     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a
prescription drug as prescribed due to cost;
     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to
create competition and help lower their prices; and
     (4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the
negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.
     (b) As used in this section, the following words shall have the following meanings:
     (1) "Complex or chronic medical condition" means a physical, behavioral, or
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that
advances over time, and:
     (i) May have no known cure;
     (ii) Is progressive; or
     (iii) Can be debilitating or fatal if left untreated or undertreated.
     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,
hepatitis c, and rheumatoid arthritis.
     (2) "Pre-service authorization" means a cost containment method that an insurer, a
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize
coverage for drugs prescribed by a health care healthcare provider for a covered individual to
control utilization, quality, and claims.
     (3) "Rare medical condition" means a disease or condition that affects fewer than:
     (i) Two hundred thousand (200,000) individuals in the United States; or
     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.
     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and
multiple myeloma.
     (4) "Specialty drug" means a prescription drug that exceeds the threshold for a specialty
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and
Modernization Act of 2003 (Public Law 108-173)).
     (5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a
cost-sharing obligation for a specialty drug.
     (c) Every individual or group health insurance contract, plan, or policy that provides
prescription drug coverage and is delivered, issued for delivery, or renewed in this state on or after
January 1, 2025, shall limit any required copayment of or coinsurance applicable to covered drugs
on a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for
each drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any
copayment or coinsurance. This limit shall be applicable after any deductible is reached and until
the individual's maximum out-of-pocket limit has been reached.
     (d) Nothing in this section shall prevent an entity subject to this section from reducing a
covered individual's cost sharing for a specialty drug to an amount less than that described in section
subsection (c) of this section.
     (e) The health insurance commissioner may promulgate any rules and regulations
necessary to implement and administer this section in accordance with any federal requirements
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of
this section.
     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance
Organizations" is hereby amended by adding thereto the following section:
     27-41-38.3. Specialty drugs.
     (a) The general assembly makes the following findings:
     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents
had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)
residents had two (2) or more chronic diseases, which significantly increases their likelihood to
depend on prescription specialty drugs;
     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a
prescription drug as prescribed due to cost;
     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to
create competition and help lower their prices; and
     (4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the
negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.
     (b) As used in this section, the following words shall have the following meanings:
     (1) "Complex or chronic medical condition" means a physical, behavioral, or
developmental condition that is persistent or otherwise long-lasting in its effects or a disease that
advances over time, and:
     (i) May have no known cure;
     (ii) Is progressive; or
     (iii) Can be debilitating or fatal if left untreated or undertreated.
     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,
hepatitis c, and rheumatoid arthritis.
     (2) "Pre-service authorization" means a cost containment method that an insurer, a
nonprofit health service plan, or a health maintenance organization uses to review and preauthorize
coverage for drugs prescribed by a health care healthcare provider for a covered individual to
control utilization, quality, and claims.
     (3) "Rare medical condition" means a disease or condition that affects fewer than:
     (i) Two hundred thousand (200,000) individuals in the United States; or
     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.
     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and
multiple myeloma.
     (4) "Specialty drug" means a prescription drug that exceeds the threshold for a specialty
drug under the Medicare Part D program (Medicare Prescription Drug Improvement and
Modernization Act of 2003 (Public Law 108-173)).
     (5) "Specialty drug tier" means a formulary tier in the pharmacy benefit that imposes a
cost-sharing obligation for a specialty drug.
     (c) Every individual or group health insurance contract, plan, or policy that provides
prescription drug coverage and is delivered, issued for delivery, or renewed in this state on or after
January 1, 2025, shall limit any required copayment of or coinsurance applicable to covered drugs
on a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for
each drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any
copayment or coinsurance. This limit shall be applicable after any deductible is reached and until
the individual's maximum out-of-pocket limit has been reached.
     (d) Nothing in this section shall prevent an entity subject to this section from reducing a
covered individual's cost sharing for a specialty drug to an amount less than that described in section
(c) of this section.
     (e) The health insurance commissioner may promulgate any rules and regulations
necessary to implement and administer this section in accordance with any federal requirements
and shall use the commissioner's enforcement powers to obtain compliance with the provisions of
this section.
     SECTION 5. This act shall take effect on January 1, 2025.
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LC001490/SUB A
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