2026 -- H 7816

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LC005053

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2026

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     

     Introduced By: Representative Charlene Lima

     Date Introduced: February 26, 2026

     Referred To: House Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance

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

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     27-18-96. Coverage denial justification and notification.

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     (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in

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§ 27-18-33.2 shall not deny coverage for a prescription drug without first providing a written notice

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containing a medically sound justification for the denial, delivered simultaneously to both the

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prescribing provider and the patient. The notice shall include sufficient detail to permit the provider

8

and patient to understand the basis for denial and, if appropriate, submit an appeal or request for

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prior authorization.

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     (1) Medical oversight requirement. Any medically sound justification required under this

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section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health

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care professional authorized under Rhode Island law to provide such clinical determinations, and

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the name and license information of the reviewing professional must be included in the written

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notice.

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     (2) Definition of medically sound justification. For purposes of this section, "medically

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sound justification" means a reason based on recognized clinical standards or evidence-based

17

guidelines appropriate to the patient’s condition.

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     (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager

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from denying coverage in accordance with the terms of the insurance plan or prescription drug

 

1

benefit contract; provided that, the written justification requirement and medical oversight

2

requirements are met.

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

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

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     27-19-88. Coverage denial justification and notification.

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     (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in

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§ 27-19-26.2 shall not deny coverage for a prescription drug without first providing a written notice

8

containing a medically sound justification for the denial, delivered simultaneously to both the

9

prescribing provider and the patient. The notice shall include sufficient detail to permit the provider

10

and patient to understand the basis for denial and, if appropriate, submit an appeal or request for

11

prior authorization.

12

     (1) Medical oversight requirement. Any medically sound justification required under this

13

section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health

14

care professional authorized under Rhode Island law to provide such clinical determinations, and

15

the name and license information of the reviewing professional must be included in the written

16

notice.

17

     (2) Definition of medically sound justification. For purposes of this section, "medically

18

sound justification" means a reason based on recognized clinical standards or evidence-based

19

guidelines appropriate to the patient’s condition.

20

     (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager

21

from denying coverage in accordance with the terms of the insurance plan or prescription drug

22

benefit contract; provided that, the written justification requirement and medical oversight

23

requirements are met.

24

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

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

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     27-20-84. Coverage denial justification and notification.

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     (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in

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§ 27-20-23.2 shall not deny coverage for a prescription drug without first providing a written notice

29

containing a medically sound justification for the denial, delivered simultaneously to both the

30

prescribing provider and the patient. The notice shall include sufficient detail to permit the provider

31

and patient to understand the basis for denial and, if appropriate, submit an appeal or request for

32

prior authorization.

33

     (1) Medical oversight requirement. Any medically sound justification required under this

34

section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health

 

LC005053 - Page 2 of 4

1

care professional authorized under Rhode Island law to provide such clinical determinations, and

2

the name and license information of the reviewing professional must be included in the written

3

notice.

4

     (2) Definition of medically sound justification. For purposes of this section, "medically

5

sound justification" means a reason based on recognized clinical standards or evidence-based

6

guidelines appropriate to the patient’s condition.

7

     (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager

8

from denying coverage in accordance with the terms of the insurance plan or prescription drug

9

benefit contract; provided that, the written justification requirement and medical oversight

10

requirements are met.

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

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

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     27-41-101. Coverage denial justification and notification.

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     (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in

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§ 27-41-38.2 shall not deny coverage for a prescription drug without first providing a written notice

16

containing a medically sound justification for the denial, delivered simultaneously to both the

17

prescribing provider and the patient. The notice shall include sufficient detail to permit the provider

18

and patient to understand the basis for denial and, if appropriate, submit an appeal or request for

19

prior authorization.

20

     (1) Medical oversight requirement. Any medically sound justification required under this

21

section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health

22

care professional authorized under Rhode Island law to provide such clinical determinations, and

23

the name and license information of the reviewing professional must be included in the written

24

notice.

25

     (2) Definition of medically sound justification. For purposes of this section, "medically

26

sound justification" means a reason based on recognized clinical standards or evidence-based

27

guidelines appropriate to the patient’s condition.

28

     (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager

29

from denying coverage in accordance with the terms of the insurance plan or prescription drug

30

benefit contract; provided that, the written justification requirement and medical oversight

31

requirements are met.

32

     SECTION 5. This act shall take effect on January 1, 2027.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

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     This act would require pharmacy benefit managers to provide medical justification for

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denying any claim for prescription drug benefits.

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     This act would take effect on January 1, 2027.

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