2020 -- S 2319 | |
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LC004405 | |
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STATE OF RHODE ISLAND | |
IN GENERAL ASSEMBLY | |
JANUARY SESSION, A.D. 2020 | |
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A N A C T | |
RELATING TO INSURANCE - PRESCRIPTION DRUG BENEFITS | |
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Introduced By: Senator Michael J. McCaffrey | |
Date Introduced: February 05, 2020 | |
Referred To: Senate Health & Human Services | |
It is enacted by the General Assembly as follows: | |
1 | SECTION 1. Sections 27-20.8-1 and 27-20.8-2 of the General Laws in Chapter 27-20.8 |
2 | entitled "Prescription Drug Benefits" are hereby amended to read as follows: |
3 | 27-20.8-1. Definitions. |
4 | For the purposes of this chapter, the following terms shall mean: |
5 | (1) "Director" shall mean the director of the department of business regulation. |
6 | (2) "Health plan" shall mean an insurance carrier as defined in chapters 18, 19, 20 and 41 |
7 | of this title. |
8 | (3) "Insured" shall mean any person who is entitled to have pharmacy services paid by a |
9 | health plan pursuant to a policy, certificate, contract or agreement of insurance or coverage |
10 | including those administered for the health plan under a contract with a third-party administrator |
11 | that manages pharmacy benefits or pharmacy network contracts. |
12 | (4) "Out-of-pocket expenditure" means a co-payment, coinsurance, deductible, or other |
13 | cost-sharing mechanism. |
14 | (5) "Pharmacy benefit manager" or "PBM" means an entity doing business in this state |
15 | that contracts to administer or manage prescription drug benefits on behalf of any carrier that |
16 | provides prescription drug benefits to residents of this state. |
17 | 27-20.8-2. Pharmacy benefit, limits and co-payments. |
18 | Any health plan that offers pharmacy benefits shall comply with the following: |
19 | (a) When a health plan's pharmacy benefit has a dollar limit, the insured's use of such |
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1 | benefit shall be determined based on the health plan's contracted rate to purchase the drug minus |
2 | the enrollee's applicable co-payment for covered drugs. The balance will apply towards the |
3 | enrollee's dollars limit. |
4 | (b) When a health plan charges a co-payment for covered prescription drugs that is based |
5 | on a percent of the drug cost, the health plan shall disclose within the group policy or individual |
6 | policy benefits description statement whether the co-payment is based on the plan's contracted |
7 | rate to purchase the drug or some other cost basis such as retail price. |
8 | (c) Health insurance or other health benefit plan offered by a health insurer or pharmacy |
9 | benefit manager shall not include an annual dollar limit on prescription drug benefits. |
10 | (d) A health plan or other health benefit plan offered by a health insurer or pharmacy |
11 | benefit manager shall limit a beneficiary's out-of-pocket expenditures for prescription drugs, |
12 | including specialty drugs, to no more for self-only and family coverage per year than the |
13 | minimum dollar amounts in effect under § 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 |
14 | for self-only and family coverage. |
15 | (e) For prescription drug benefits offered in conjunction with a high-deductible health |
16 | plan (HDHP), the plan may not provide prescription drug benefits until the expenditures |
17 | applicable to the deductible under the HDHP have met the amount of the minimum annual |
18 | deductibles in effect for self-only and family coverage under § 223(c)(2)(A)(i) of the Internal |
19 | Revenue Code of 1986 for self-only and family coverage, respectively. Once the foregoing |
20 | expenditure amount has been met under the HDHP, coverage for prescription drug benefits shall |
21 | begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as |
22 | specified in subsection (d) of this section. |
23 | (f) The health insurance commissioner may use any of their enforcement powers to |
24 | obtain a carrier's compliance with this section. |
25 | SECTION 2. This act shall take effect upon passage and shall apply to all health plans |
26 | pursuant to a policy, certificate, contract or agreement of insurance or coverage including those |
27 | administered for health plans under a contract with a third-party administrator that manages |
28 | pharmacy benefits or pharmacy network contracts issued on or after January 1, 2021. |
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EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO INSURANCE - PRESCRIPTION DRUG BENEFITS | |
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1 | This act would limit a beneficiary's out-of-pocket expenditures for prescription drugs to |
2 | limits established for self-only and family coverage per year contained in the Internal Revenue |
3 | Code. |
4 | This act would take effect upon passage and would apply to all health plans pursuant to a |
5 | policy, certificate, contract or agreement of insurance or coverage including those administered |
6 | for health plans under a contract with a third-party administrator that manages pharmacy benefits |
7 | or pharmacy network contracts issued on or after January 1, 2021. |
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