2017 -- H 5895

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LC001720

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2017

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A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives Maldonado, Diaz, Messier, O`Grady, and Casey

     Date Introduced: March 09, 2017

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

     SECTION 1. Section 27-18-50.1 of the General Laws in Chapter 27-18 entitled

"Accident and Sickness Insurance Policies" is hereby amended to read as follows:

     27-18-50.1. Medication synchronization.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

or renewed in this state on or after January 1, 2017, providing prescription drug coverage in the

state, must permit and apply a prorated, daily cost-sharing rate to covered prescriptions for a

chronic condition that are dispensed by an in-network pharmacy for less than a thirty (30) days'

supply if the prescriber and pharmacist determine the fill or refill to be in the best interest of the

patient for the management or treatment of a chronic, long-term care condition and the patient

requests or agrees to less than a thirty (30) days' supply for the purpose of synchronizing the

patient's medications and the insured's or enrollee's maintenance prescription drug(s) to be

synchronized meets all of the following requirements:

     (1) Is covered by the policy, certificate, or contract described in this chapter;

     (2) Is used for the management and treatment of a chronic, long-term care condition and

have authorized refills that remain available to the insured or enrollee;

     (3) Except as otherwise provided in this subparagraph, is not a controlled substance

included in schedules II to V;

     (4) Meets all utilization management requirements specific to the maintenance-

prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple,

maintenance-prescription drugs;

     (5) Is of a formulation that can be effectively split over required short-fill periods to

achieve synchronization; and

     (6) Does not have quantity limits or dose-optimization criteria or requirements that will

be violated when synchronizing the insured's or enrollee's multiple, maintenance-prescription

drugs.

     (b) The plan or policy described in subsection (a) shall apply a prorated, daily cost-

sharing rate for maintenance-prescription drugs that are dispensed by an in-network pharmacy for

the purpose of synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.

     (c) The plan or policy described in subsection (a) shall not reimburse or pay any

dispensing fee that is prorated. The insurer shall only pay or reimburse a dispensing fee that is

based on each maintenance-prescription drug dispensed.

     (d) A synchronization shall only occur once per year per maintenance-prescription drug.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

or renewed in this state on or after January 1, 2018, providing prescription drug coverage must

permit and apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a

network pharmacy for a partial supply if the prescriber or pharmacist determines the fill or refill

to be in the best interest of the patient and the patient requests or agrees to a partial supply for the

purpose of synchronizing the patient's medications.

     (b) No individual or group health insurance policy providing prescription drug coverage

shall deny coverage for the dispensing of a medication that is dispensed by a network pharmacy

on the basis that the dispensing is for a partial supply if the prescriber or pharmacist determines

the fill or refill to be in the best interest of the patient and the patient requests or agrees to a

partial supply for the purpose of synchronizing the patient's medications. The individual or group

health plan must allow a pharmacy to override any denial codes indicating that a prescription is

being refilled too soon for the purposes of medication synchronization.

     (c) No individual or group health insurance policy providing prescription drug coverage

shall use payment structures incorporating prorated dispensing fees. Dispensing fees for partially

filled or refilled prescriptions shall be paid in full for each prescription dispensed, regardless of

any prorated copay for the beneficiary or fee paid for alignment services.

     SECTION 2. Section 27-19-26.1 of the General Laws in Chapter 27-19 entitled

"Nonprofit Hospital Service Corporations" is hereby amended to read as follows:

     27-19-26.1. Medication synchronization.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

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or renewed in this state on or after January 1, 2017, providing prescription drug coverage in the

state, must permit and apply a prorated, daily cost-sharing rate to covered prescriptions for a

chronic condition that are dispensed by an in-network pharmacy for less than a thirty (30) days'

supply if the prescriber and pharmacist determine the fill or refill to be in the best interest of the

patient for the management or treatment of a chronic, long-term care condition and the patient

requests or agrees to less than a thirty (30) days' supply for the purpose of synchronizing the

patient's medications and the insured's or enrollee's maintenance-prescription drug(s) to be

synchronized meets all of the following requirements:

     (1) Is covered by the policy, certificate, or contract described in this chapter;

     (2) Is used for the management and treatment of a chronic, long-term care condition and

have authorized refills that remain available to the insured or enrollee;

     (3) Except as otherwise provided in this subparagraph, is not a controlled substance

included in schedules II to V;

     (4) Meets all utilization management requirements specific to the maintenance-

prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple,

maintenance-prescription drugs;

     (5) Is of a formulation that can be effectively split over required short-fill periods to

achieve synchronization; and

     (6) Does not have quantity limits or dose-optimization criteria or requirements that will

be violated when synchronizing the insured's or enrollee's multiple maintenance-prescription

drugs.

     (b) The plan or policy described in subsection (a) shall apply a prorated, daily cost-

sharing rate for maintenance-prescription drugs that are dispensed by an in-network pharmacy for

the purpose of synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.

     (c) The plan or policy described in subsection (a) shall not reimburse or pay any

dispensing fee that is prorated. The insurer shall only pay or reimburse a dispensing fee that is

based on each maintenance-prescription drug dispensed.

     (d) A synchronization shall only occur once per year per maintenance-prescription drug.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

or renewed in this state on or after January 1, 2018, providing prescription drug coverage must

permit and apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a

network pharmacy for a partial supply if the prescriber or pharmacist determines the fill or refill

to be in the best interest of the patient and the patient requests or agrees to a partial supply for the

purpose of synchronizing the patient's medications.

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     (b) No individual or group health insurance policy providing prescription drug coverage

shall deny coverage for the dispensing of a medication that is dispensed by a network pharmacy

on the basis that the dispensing is for a partial supply if the prescriber or pharmacist determines

the fill or refill to be in the best interest of the patient and the patient requests or agrees to a

partial supply for the purpose of synchronizing the patient's medications. The individual or group

health plan must allow a pharmacy to override any denial codes indicating that a prescription is

being refilled too soon for the purposes of medication synchronization.

     (c) No individual or group health insurance policy providing prescription drug coverage

shall use payment structures incorporating prorated dispensing fees. Dispensing fees for partially

filled or refilled prescriptions shall be paid in full for each prescription dispensed, regardless of

any prorated copay for the beneficiary or fee paid for alignment services.

     SECTION 3. Section 27-20-23.1 of the General Laws in Chapter 27-20 entitled

"Nonprofit Medical Service Corporations" is hereby amended to read as follows:

     27-20-23.1. Medication synchronization.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

or renewed in this state on or after January 1, 2017, providing prescription drug coverage in the

state, must permit and apply a prorated, daily cost-sharing rate to covered prescriptions for a

chronic condition that are dispensed by an in-network pharmacy for less than a thirty (30) days'

supply if the prescriber and pharmacist determine the fill or refill to be in the best interest of the

patient for the management or treatment of a chronic, long-term care condition and the patient

requests or agrees to less than a thirty (30) days' supply for the purpose of synchronizing the

patient's medications and the insured's or enrollee's maintenance-prescription drug(s) to be

synchronized meets all of the following requirements:

     (1) Is covered by the policy, certificate, or contract described in this chapter;

     (2) Is used for the management and treatment of a chronic, long-term care condition and

have authorized refills that remain available to the insured or enrollee;

     (3) Except as otherwise provided in this subparagraph, is not a controlled substance

included in schedules II to V;

     (4) Meets all utilization management requirements specific to the maintenance-

prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple,

maintenance-prescription drugs;

     (5) Is of a formulation that can be effectively split over required short-fill periods to

achieve synchronization; and

     (6) Does not have quantity limits or dose-optimization criteria or requirements that will

LC001720 - Page 4 of 8

be violated when synchronizing the insured's or enrollee's multiple, maintenance-prescription

drugs.

     (b) The plan or policy described in subsection (a) shall apply a prorated, daily cost-

sharing rate for maintenance-prescription drugs that are dispensed by an in-network pharmacy for

the purpose of synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.

     (c) The plan or policy described in subsection (a) shall not reimburse or pay any

dispensing fee that is prorated. The insurer shall only pay or reimburse a dispensing fee that is

based on each maintenance-prescription drug dispensed.

     (d) A synchronization shall only occur once per year per maintenance-prescription drug.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

or renewed in this state on or after January 1, 2018, providing prescription drug coverage must

permit and apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a

network pharmacy for a partial supply if the prescriber or pharmacist determines the fill or refill

to be in the best interest of the patient and the patient requests or agrees to a partial supply for the

purpose of synchronizing the patient's medications.

     (b) No individual or group health insurance policy providing prescription drug coverage

shall deny coverage for the dispensing of a medication that is dispensed by a network pharmacy

on the basis that the dispensing is for a partial supply if the prescriber or pharmacist determines

the fill or refill to be in the best interest of the patient and the patient requests or agrees to a

partial supply for the purpose of synchronizing the patient's medications. The individual or group

health plan must allow a pharmacy to override any denial codes indicating that a prescription is

being refilled too soon for the purposes of medication synchronization.

     (c) No individual or group health insurance policy providing prescription drug coverage

shall use payment structures incorporating prorated dispensing fees. Dispensing fees for partially

filled or refilled prescriptions shall be paid in full for each prescription dispensed, regardless of

any prorated copay for the beneficiary or fee paid for alignment services.

     SECTION 4. Section 27-41-38.1 of the General Laws in Chapter 27-41 entitled "Health

Maintenance Organizations" is hereby amended to read as follows:

     27-41-38.1. Medication synchronization.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

or renewed in this state on or after January 1, 2017, providing prescription drug coverage in the

state, must permit and apply a prorated daily cost-sharing rate to covered prescriptions for a

chronic condition that are dispensed by an in-network pharmacy for less than a thirty (30) days'

supply if the prescriber and pharmacist determine the fill or refill to be in the best interest of the

LC001720 - Page 5 of 8

patient for the management or treatment of a chronic, long-term care condition and the patient

requests or agrees to less than a thirty (30) days' supply for the purpose of synchronizing the

patient's medications and the insured's or enrollee's maintenance-prescription drug(s) to be

synchronized meets all of the following requirements:

     (1) Is covered by the policy, certificate, or contract described in this chapter;

     (2) Is used for the management and treatment of a chronic, long-term care condition and

have authorized refills that remain available to the insured or enrollee;

     (3) Except as otherwise provided in this subparagraph, is not a controlled substance

included in schedules II to V;

     (4) Meets all utilization management requirements specific to the maintenance-

prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple,

maintenance-prescription drugs;

     (5) Is of a formulation that can be effectively split over required short-fill periods to

achieve synchronization; and

     (6) Does not have quantity limits or dose-optimization criteria or requirements that will

be violated when synchronizing the insured's or enrollee's multiple, maintenance-prescription

drugs.

     (b) The plan or policy described in subsection (a) shall apply a prorated, daily cost-

sharing rate for maintenance-prescription drugs that are dispensed by an in-network pharmacy for

the purpose of synchronizing the insured's or enrollee's multiple, maintenance-prescription drugs.

     (c) The plan or policy described in subsection (a) shall not reimburse or pay any

dispensing fee that is prorated. The insurer shall only pay or reimburse a dispensing fee that is

based on each maintenance-prescription drug dispensed.

     (d) A synchronization shall only occur once per year per maintenance-prescription drug.

     (a) An individual or group health insurance plan or policy delivered, issued for delivery,

or renewed in this state on or after January 1, 2018, providing prescription drug coverage must

permit and apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a

network pharmacy for a partial supply if the prescriber or pharmacist determines the fill or refill

to be in the best interest of the patient and the patient requests or agrees to a partial supply for the

purpose of synchronizing the patient's medications.

     (b) No individual or group health insurance policy providing prescription drug coverage

shall deny coverage for the dispensing of a medication that is dispensed by a network pharmacy

on the basis that the dispensing is for a partial supply if the prescriber or pharmacist determines

the fill or refill to be in the best interest of the patient and the patient requests or agrees to a

LC001720 - Page 6 of 8

partial supply for the purpose of synchronizing the patient's medications. The individual or group

health plan must allow a pharmacy to override any denial codes indicating that a prescription is

being refilled too soon for the purposes of medication synchronization.

     (c) No individual or group health insurance policy providing prescription drug coverage

shall use payment structures incorporating prorated dispensing fees. Dispensing fees for partially

filled or refilled prescriptions shall be paid in full for each prescription dispensed, regardless of

any prorated copay for the beneficiary or fee paid for alignment services.

     SECTION 5. This act shall take effect on January 1, 2018.

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LC001720

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

***

     This act would require that an individual or group health plan or policy delivered, issued

for delivery, or renewed on or after January 1, 2018 allow for a partial supply of prescriptions for

the purpose of synchronizing a patient's medication.

     This act would take effect on January 1, 2018.

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LC001720

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