Title 27
Insurance

Chapter 19
Nonprofit Hospital Service Corporations

§ 27-19-26.3. Patient choice in dispensing of clinician-administered drugs. [Effective January 1, 2025.]

(a) As used in this section,

(1) “Clinician-administered drug” means an outpatient infused prescription drug other than a vaccine that:

(i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed or by a non-clinician individual assisting the patient with the self-administration; and

(ii) Is typically administered:

(A) By a healthcare professional authorized under the laws of this state to administer the drug, including when acting under a physician’s delegation and supervision; and

(B) In a physician’s office, hospital outpatient infusion center, or other clinical setting.

(b) A health insurer or a third party acting on its behalf shall not refuse to authorize, approve, or pay a provider for a covered clinician-administered drug that was administered and dispensed by any in-network hospital or clinic; provided that:

(1) The dispensing and administering and any associated authorizations and approvals are consistent with the provider contract and the issuer’s medical and payment policies provided such policies do not prohibit the procurement, administration, and dispensing by an in-network hospital or clinic; and

(2) The reimbursement to the provider shall be negotiated between the health insurer and provider at a rate equal to payments between the insurer and a preferred pharmacy.

(c) After January 1, 2025, the office of the health insurance commissioner, in consultation with health insurers and providers, shall conduct an analysis of the payment for clinician-administered drugs under this section.

(1) In conducting the analysis, the office of the health insurance commissioner may:

(i) Gather data from providers regarding potentially inaccurate payments; and

(ii) Obtain necessary information from health insurers to understand how reimbursements to providers for clinician-administered drugs are calculated.

(2) The office of the health insurance commissioner shall publish on its website a summary of its analysis, without identifying any health insurers or providers.

(3) The office of the health insurance commissioner may include in its analysis legislative recommendations to improve the reimbursement process for clinician-administered drugs under this section, as necessary. Any recommendations shall include a description of the recommendation’s potential costs to consumers, health insurers, providers, and the state.

(4) The office of the health insurance commissioner shall provide the general assembly with their analysis no later than February 28, 2026.