2014 -- H 8201

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LC005656

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO INSURANCE -- COVERAGE FOR PRESCRIPTION DRUGS

     Introduced By: Representatives O`Grady, Amore, Ackerman, Cimini, and Ajello

     Date Introduced: May 15, 2014

     Referred To: House Corporations

     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 sections:

     27-18-82. Establishing prescription drug out-of-pocket limits. -- (a) As used in this

section:

     (1) "Out-of-pocket expenditure" means all and any co-payment, co-insurance, deductible,

or other cost-sharing mechanism.

     (b) A health plan that provides coverage for prescription drugs shall:

     (1) Ensure that any required out-of-pocket expenditure applicable to a prescription drug

does not exceed one hundred dollars ($100) per month for such prescription drug up to a thirty

(30) day supply; and

     (2) Limit a beneficiary's annual out-of-pocket expenditures for prescription drugs to no

more than fifty percent (50%) of the dollar amounts in accordance with 42 U.S.C. 1302(c)(1) of

the Federal Affordable Care Act for self-only and family coverage, respectively.

     (c) Nothing in this section shall be construed to require a health plan to provide coverage

for any additional drugs not otherwise required by law.

     27-18-83. Step-therapy programs. -- (a) As used in this section the following words

shall, unless the context clearly requires otherwise, have the following meanings:

     (1) "Step therapy" means protocols that establish the specific sequence in which

prescription drugs for a specified medical condition are to be prescribed.

     (b) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or

renewed within the state that provides coverage for prescription drugs and uses step-therapy

protocols shall:

     (1) Provide the prescriber with a clear and convenient process to expeditiously request an

override of such restriction, which shall be granted whenever the prescriber can demonstrate that:

     (i) The patient is currently stabilized on the treatment which is being requested; or

     (ii) The preferred treatment required under the step-therapy program:

     (A) Has been ineffective in the treatment of the patient's medical condition in the past;

     (B) Is expected to be ineffective or adversely affect treatment compliance based on the

known relevant physical or mental characteristics of the patient and the known characteristics of

the drug regimen; or

     (C) Will cause or will likely cause an adverse reaction or other physical harm to the

patient.

     (2) Step-therapy protocols described in this section shall not exceed the earlier of:

     (i) The period deemed necessary by the patient's prescriber to determine clinical

effectiveness of the preferred treatment required under the step-therapy program; or

     (ii) Ten (10) days.

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

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

     27-19-73. Establishing prescription drug out-of-pockets limits. -- (a) As used in this

section:

     (1) "Out-of-pocket expenditure" means all and any co-payment, co-insurance, deductible,

or other cost-sharing mechanism.

     (b) A health plan that provides coverage for prescription drugs shall:

     (1) Ensure that any required out-of-pocket expenditure applicable to a prescription drug

does not exceed one hundred dollars ($100) per month for such prescription drug up to a thirty

(30) day supply; and

     (2) Limit a beneficiary's annual out-of-pocket expenditures for prescription drugs to no

more than fifty percent (50%) of the dollar amounts in accordance with 42 U.S.C. 1302(c)(1) of

the Federal Affordable Care Act for self-only and family coverage, respectively.

     (c) Nothing in this section shall be construed to require a health plan to provide coverage

for any additional drugs not otherwise required by law.

     27-19-74. Step-therapy programs. -- (a) As used in this section the following words

shall, unless the context clearly requires otherwise, have the following meanings:

LC005656 - Page 2 of 6

     (1) "Step therapy" means protocols that establish the specific sequence in which

prescription drugs for a specified medical condition are to be prescribed.

     (b) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or

renewed within the state that provides coverage for prescription drugs and uses step-therapy

protocols shall:

     (1) Provide the prescriber with a clear and convenient process to expeditiously request an

override of such restriction, which shall be granted whenever the prescriber can demonstrate that:

     (i) The patient is currently stabilized on the treatment which is being requested; or

     (ii) The preferred treatment required under the step-therapy program:

     (A) Has been ineffective in the treatment of the patient's medical condition in the past;

     (B) Is expected to be ineffective or adversely affect treatment compliance based on the

known relevant physical or mental characteristics of the patient and the known characteristics of

the drug regimen; or

     (C) Will cause or will likely cause an adverse reaction or other physical harm to the

patient.

     (2) Step-therapy protocols described in this section shall not exceed the earlier of:

     (i) The period deemed necessary by the patient's prescriber to determine clinical

effectiveness of the preferred treatment required under the step-therapy program; or

     (ii) Ten (10) days.

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

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

     27-20-69. Establishing prescription drug out-of-pocket limits. -- (a) As used in this

section:

     (1) "Out-of-pocket expenditure" means all and any co-payment, co-insurance, deductible,

or other cost-sharing mechanism.

     (b) A health plan that provides coverage for prescription drugs shall:

     (1) Ensure that any required out-of-pocket expenditure applicable to a prescription drug

does not exceed one hundred dollars ($100) per month for such prescription drug up to a thirty

(30) day supply; and

     (2) Limit a beneficiary's annual out-of-pocket expenditures for prescription drugs to no

more than fifty percent (50%) of the dollar amounts in accordance with 42 U.S.C. 1302(c)(1) of

the Federal Affordable Care Act for self-only and family coverage, respectively.

     (c) Nothing in this section shall be construed to require a health plan to provide coverage

LC005656 - Page 3 of 6

for any additional drugs not otherwise required by law.

     27-20-70. Step-therapy programs. -- (a) As used in this section the following words

shall, unless the context clearly requires otherwise, have the following meanings:

     (1) "Step therapy" means protocols that establish the specific sequence in which

prescription drugs for a specified medical condition are to be prescribed.

     (b) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or

renewed within the state that provides coverage for prescription drugs and uses step-therapy

protocols shall:

     (1) Provide the prescriber with a clear and convenient process to expeditiously request an

override of such restriction, which shall be granted whenever the prescriber can demonstrate that:

     (i) The patient is currently stabilized on the treatment which is being requested; or

     (ii) The preferred treatment required under the step-therapy program:

     (A) Has been ineffective in the treatment of the patient's medical condition in the past;

     (B) Is expected to be ineffective or adversely affect treatment compliance based on the

known relevant physical or mental characteristics of the patient and the known characteristics of

the drug regimen; or

     (C) Will cause or will likely cause an adverse reaction or other physical harm to the

patient.

     (2) Step-therapy protocols described in this section shall not exceed the earlier of:

     (i) The period deemed necessary by the patient's prescriber to determine clinical

effectiveness of the preferred treatment required under the step-therapy program; or

     (ii) Ten (10) days.

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

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

     27-41-86. Establishing prescription drug out-of-pocket limits. -- (a) As used in this

section:

     (1) "Out-of-pocket expenditure" means all and any co-payment, co-insurance, deductible,

or other cost-sharing mechanism.

     (b) A health plan that provides coverage for prescription drugs shall:

     (1) Ensure that any required out-of-pocket expenditure applicable to a prescription drug

does not exceed one hundred dollars ($100) per month for such prescription drug up to a thirty

(30) day supply; and

     (2) Limit a beneficiary's annual out-of-pocket expenditures for prescription drugs to no

more than fifty percent (50%) of the dollar amounts in accordance with 42 U.S.C. 1302(c)(1) of

LC005656 - Page 4 of 6

the Federal Affordable Care Act for self-only and family coverage, respectively.

     (c) Nothing in this section shall be construed to require a health plan to provide coverage

for any additional drugs not otherwise required by law.

     27-41-87. Step-therapy programs. -- (a) As used in this section the following words

shall, unless the context clearly requires otherwise, have the following meanings:

     (1) "Step therapy" means protocols that establish the specific sequence in which

prescription drugs for a specified medical condition are to be prescribed.

     (b) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or

renewed within the state that provides coverage for prescription drugs and uses step-therapy

protocols shall:

     (1) Provide the prescriber with a clear and convenient process to expeditiously request an

override of such restriction, which shall be granted whenever the prescriber can demonstrate that:

     (i) The patient is currently stabilized on the treatment which is being requested; or

     (ii) The preferred treatment required under the step-therapy program:

     (A) Has been ineffective in the treatment of the patient's medical condition in the past;

     (B) Is expected to be ineffective or adversely affect treatment compliance based on the

known relevant physical or mental characteristics of the patient and the known characteristics of

the drug regimen; or

     (C) Will cause or will likely cause an adverse reaction or other physical harm to the

patient.

     (2) Step-therapy protocols described in this section shall not exceed the earlier of:

     (i) The period deemed necessary by the patient's prescriber to determine clinical

effectiveness of the preferred treatment required under the step-therapy program; or

     (ii) Ten (10) days.

     SECTION 5. This act shall take effect upon passage.

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LC005656

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- COVERAGE FOR PRESCRIPTION DRUGS

***

     This act would limit the out-of-pocket expense for prescription drugs. It would also

define "step therapy" as a specific sequence in which drugs are prescribed for a specified medical

condition. It would also spell out the procedure a prescriber must follow in order to be able to

quickly obtain authority to override certain restrictions on behalf of a patient.

     This act would take effect upon passage.

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LC005656

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