2024 -- H 7897

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LC004226

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2024

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A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE -- PRESCRIPTION

DRUGS

     Introduced By: Representatives Casey, Potter, Speakman, Donovan, Fenton-Fung,
Kislak, Serpa, Cortvriend, Phillips, and Chippendale

     Date Introduced: March 04, 2024

     Referred To: House Finance

     It is enacted by the General Assembly as follows:

     SECTION 1. Chapter 40-21 of the General Laws entitled "Medical Assistance —

Prescription Drugs" is hereby amended by adding thereto the following section:

     40-21-4. Prohibition of prior authorization or step therapy protocol.

     (a) The Rhode Island state plan for medical assistance program, as defined by this chapter,

and any contract between the Rhode Island medical assistance program, as defined under chapter

8 of title 40, and a managed care organization shall not require prior authorization or a step therapy

protocol for the prescription of a nonpreferred medication on their drug formulary used to assess

or treat an enrollee’s bipolar disorder, schizophrenia or schizotypal disorder, major depressive

disorder, or post-traumatic stress disorder as defined by the American Psychiatric Association’s

Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or an epilepsy or seizure

disorder; if:

     (1) The enrollee has been previously prescribed and filled or refilled a nonpreferred

medication to treat bipolar disorder, schizophrenia or schizotypal disorder, major depressive

disorder, or post-traumatic stress disorder as defined by the American Psychiatric Association’s

Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or an epilepsy or seizure

disorder;

     (2) A preferred medication to treat bipolar disorder, schizophrenia or schizotypal disorder,

major depressive disorder, or post-traumatic stress disorder as defined by the American Psychiatric

Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or an epilepsy

or seizure disorder has been tried by the enrollee and has failed to produce the desired health

outcomes;

     (3) The enrollee has tried a preferred medication to treat bipolar disorder, schizophrenia or

schizotypal disorder, major depressive disorder, or post-traumatic stress disorder as defined by the

American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth

edition or an epilepsy or seizure disorder and has experienced unacceptable side effects;

     (4) The enrollee has been stabilized on a nonpreferred medication to treat bipolar disorder,

schizophrenia or schizotypal disorder, major depressive disorder, or post-traumatic stress disorder

as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental

Disorders, fifth edition or an epilepsy or seizure disorder and transition to the preferred medication

would be medically contraindicated;

     (5) The enrollee was prescribed and unsuccessfully treated with a preferred medication to

treat bipolar disorder, schizophrenia or schizotypal disorder, major depressive disorder, or post-

traumatic stress disorder as defined by the American Psychiatric Association’s Diagnostic and

Statistical Manual of Mental Disorders, fifth edition or an epilepsy or seizure disorder and at least

a single claim was paid; or

     (6) Upon confirmation of the enrollee’s inpatient utilization, the enrollee is stable on a

nonpreferred medication to treat bipolar disorder, schizophrenia or schizotypal disorder, major

depressive disorder, or post-traumatic stress disorder as defined by the American Psychiatric

Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition or an epilepsy

or seizure disorder that was ordered by their health care provider in an inpatient setting.

     (b) If it is determined that authorization from a federal agency is necessary for the

implementation of this section, the executive office of health and human services is authorized to

seek such state plan amendment and may delay implementing the provisions until the authorization

is granted.

     (c) The Rhode Island medical assistance program, as defined under chapter 8 of title 40,

shall require through amending current and future medical assistance managed care contracts, that

the managed care organizations meet the provisions of this section.

     (d) This section does not prevent the Rhode Island medical assistance program, as defined

under chapter 8 of title 40, and any contract between the Rhode Island medical assistance program

and a managed care organization from denying an exception for a medication that has been removed

from the market due to safety concerns from the federal Food and Drug Administration.

     (e) For the purposes of this section, "step therapy protocol" means a protocol that

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establishes a specific sequence in which prescription medications for a specified medical condition

is medically necessary for a particular enrollee and is covered under a pharmacy or medical benefit

by a carrier, including self-administered and physician-administered drugs.

     SECTION 2. This act shall take effect upon passage and applies to all healthcare policies,

contracts, plans, and certificates executed, delivered, issued for delivery, continued or renewed in

this state on or after January 1, 2025.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO HUMAN SERVICES -- MEDICAL ASSISTANCE -- PRESCRIPTION

DRUGS

***

     This act would prohibit the Rhode Island medical assistance program, and any contract

between the Rhode Island medical assistance program and a managed care organization from

utilizing or requiring prior authorization or a step therapy protocol for the prescription of a

nonpreferred medication on their drug formulary used to assess or treat an enrollee’s bipolar

disorder, schizophrenia or schizotypal disorder, major depressive disorder, or post-traumatic stress

disorder as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual

of Mental Disorders, fifth edition, or an epilepsy or seizure disorder under certain circumstances.

     This act would take effect upon passage and apply to all healthcare policies, contracts, and

plans executed, delivered, issued for delivery, continued or renewed in this state on or after January

1, 2025.

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