2024 -- S 2380 SUBSTITUTE A

========

LC004628/SUB A

========

     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2024

____________

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Senators Bissaillon, DiMario, and Gallo

     Date Introduced: February 12, 2024

     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

Policies" is hereby amended by adding thereto the following section:

     27-18-95. Prohibition of prior authorization or step therapy protocol.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state shall not require prior authorization or a step therapy protocol for the

prescription of a nonpreferred medication classified as an anticonvulsant or antipsychotic on their

drug formulary; if:

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

medication classified as an anticonvulsant or antipsychotic;

     (2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried

by the enrollee and has failed to produce the desired health outcomes;

     (3) The enrollee has tried a preferred mediation classified as an anticonvulsant or

antipsychotic and has experienced unacceptable side effects;

     (4) The enrollee has been stabilized on a nonpreferred medication classified as an

anticonvulsant or antipsychotic and transition to the preferred medication would be medically

contraindicated.

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

classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or

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

nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their

health care provider in an inpatient setting.

     (b) The provisions of subsection (a) of this section does not affect clinical prior

authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic.

     (c) This section does prevent an individual or group health insurance contract, an individual

or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for

delivery, or renewed in this state 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.

     (d) For the purposes of this section, “step therapy protocol” means a protocol that

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

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

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

     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

Corporations" is hereby amended by adding thereto the following section:

     27-19-87. Prohibition of prior authorization or step therapy protocol.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state shall not require prior authorization or a step therapy protocol for the

prescription of a nonpreferred medication classified as an anticonvulsant or antipsychotic on their

drug formulary; if:

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

medication classified as an anticonvulsant or antipsychotic;

     (2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried

by the enrollee and has failed to produce the desired health outcomes;

     (3) The enrollee has tried a preferred mediation classified as an anticonvulsant or

antipsychotic and has experienced unacceptable side effects;

     (4) The enrollee has been stabilized on a nonpreferred medication classified as an

anticonvulsant or antipsychotic and transition to the preferred medication would be medically

contraindicated.

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

classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or

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

nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their

LC004628/SUB A - Page 2 of 6

health care provider in an inpatient setting.

     (b) The provisions of subsection (a) of this section does not affect clinical prior

authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic.

     (c) This section does prevent an individual or group health insurance contract, an individual

or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for

delivery, or renewed in this state 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.

     (d) For the purposes of this section, “step therapy protocol” means a protocol that

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

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

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

     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

Corporations" is hereby amended by adding thereto the following section:

     27-20-83. Prohibition of prior authorization or step therapy protocol.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state shall not require prior authorization or a step therapy protocol for the

prescription of a nonpreferred medication classified as an anticonvulsant or antipsychotic on their

drug formulary; if:

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

medication classified as an anticonvulsant or antipsychotic;

     (2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried

by the enrollee and has failed to produce the desired health outcomes;

     (3) The enrollee has tried a preferred mediation classified as an anticonvulsant or

antipsychotic and has experienced unacceptable side effects;

     (4) The enrollee has been stabilized on a nonpreferred medication classified as an

anticonvulsant or antipsychotic and transition to the preferred medication would be medically

contraindicated.

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

classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or

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

nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their

health care provider in an inpatient setting.

     (b) The provisions of subsection (a) of this section does not affect clinical prior

LC004628/SUB A - Page 3 of 6

authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic.

     (c) This section does prevent an individual or group health insurance contract, an individual

or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for

delivery, or renewed in this state 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.

     (d) For the purposes of this section, “step therapy protocol” means a protocol that

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

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

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

     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance

Organizations" is hereby amended by adding thereto the following section:

     27-41-100. Prohibition of prior authorization or step therapy protocol.

     (a) Every individual or group health insurance contract, or every individual or group

hospital or medical expense insurance policy, plan, or group policy delivered, issued for delivery,

or renewed in this state shall not require prior authorization or a step therapy protocol for the

prescription of a nonpreferred medication classified as an anticonvulsant or antipsychotic on their

drug formulary; if:

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

medication classified as an anticonvulsant or antipsychotic;

     (2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried

by the enrollee and has failed to produce the desired health outcomes;

     (3) The enrollee has tried a preferred mediation classified as an anticonvulsant or

antipsychotic and has experienced unacceptable side effects;

     (4) The enrollee has been stabilized on a nonpreferred medication classified as an

anticonvulsant or antipsychotic and transition to the preferred medication would be medically

contraindicated.

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

classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or

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

nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their

health care provider in an inpatient setting.

     (b) The provisions of subsection (a) of this section does not affect clinical prior

authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic.

     (c) This section does prevent an individual or group health insurance contract, an individual

LC004628/SUB A - Page 4 of 6

or group hospital or medical expense insurance policy, plan, or group policy delivered, issued for

delivery, or renewed in this state 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.

     (d) For the purposes of this section, “step therapy protocol” means a protocol that

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

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

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

     SECTION 5. 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 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 classified as an anticonvulsant or antipsychotic

on their drug formulary if:

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

medication classified as an anticonvulsant or antipsychotic;

     (2) A preferred medication classified as an anticonvulsant or antipsychotic has been tried

by the enrollee and has failed to produce the desired health outcomes;

     (3) The enrollee has tried a preferred mediation classified as an anticonvulsant or

antipsychotic and has experienced unacceptable side effects;

     (4) The enrollee has been stabilized on a nonpreferred medication classified as an

anticonvulsant or antipsychotic and transition to the preferred medication would be medically

contraindicated.

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

classified as an anticonvulsant or antipsychotic for which a least single claim was paid; or

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

nonpreferred medication classified as an anticonvulsant or antipsychotic that was ordered by their

health care provider in an inpatient setting.

     (b) If the secretary of health and human services determines 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,

LC004628/SUB A - Page 5 of 6

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

the managed care organizations meet the provisions of this section.

     (d) The provisions of subsection (a) of this section does not affect clinical prior

authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic.

     (e) This section does 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.

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

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

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

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

     SECTION 6. This act shall take effect upon passage and applies to all policies, contracts,

and certificates executed, delivered, issued for delivery, continued or renewed in this state on or

after January 1, 2025.

========

LC004628/SUB A

========

LC004628/SUB A - Page 6 of 6

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

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

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 epilepsy or seizure disorder under certain circumstances.

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

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

1, 2025.

========

LC004628/SUB A

========

LC004628/SUB A - Page 7 of 6