2014 -- S 2501

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LC004682

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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 - PRESCRIPTION DRUG COVERAGE

     Introduced By: Senators Nesselbush, Cool Rumsey, and Goldin

     Date Introduced: February 27, 2014

     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:

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

section, the following words shall have the following meaning:

     (1) "Out-of-pocket expenditure" means any and all co-payment, coinsurance, 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 drug does not

exceed one hundred dollars ($100) per month for up to a thirty (30) day supply of such drug; 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 effect under section 1302(c)(1) of the U.S.

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; and

     (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 section:

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

section, the following words shall have the following meaning:

     (1) "Out-of-pocket expenditure" means any and all co-payment, coinsurance, 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 drug does not

exceed one hundred dollars ($100) per month for up to a thirty (30) day supply of such drug; 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 effect under section 1302(c)(1) of the U.S.

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:

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

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

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     (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; and

     (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 section:

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

section, the following words shall have the following meaning:

     (1) "Out-of-pocket expenditure" means any and all co-payment, coinsurance, 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 drug does not

exceed one hundred ($100) per month for up to a thirty (30) day supply of such drug; 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 effect under section 1302(c)(1) of the U.S.

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.

     27-20-70. 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

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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; and

     (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 section:

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

section, the following words shall have the following meaning:

     (1) "Out-of-pocket expenditure" means any and all co-payment, coinsurance, 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 drug does not

exceed one hundred ($100) per month for up to a thirty (30) day supply of such drug; 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 effect under section 1302(c)(1) of the U.S.

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:

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     (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; and

     (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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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - PRESCRIPTION DRUG COVERAGE

***

     This act would require all health insurance plans issued in this state that provide

coverage for prescription drugs, to provide coverage for short term "step-therapy" prescription

programs. The act would spell out the conditions under which a prescriber would be permitted to

override certain drug restrictions.

     This act would take effect upon passage.

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