2022 -- H 8254

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LC005965

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2022

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives Caldwell, and McGaw

     Date Introduced: May 13, 2022

     Referred To: House 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:

     27-18-33.3. Patient choice in dispensing of clinician-administered drugs.

     (a) As used in this section:

     (1) "Clinician-administered drug" means an outpatient prescription drug other than a

vaccine that:

     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed

or by an individual assisting the patient with the self-administration; and

     (ii) Is typically administered:

     (A) By a health care provider authorized under the laws of this state to administer the drug,

including when acting under a physician's delegation and supervision; and

     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.

     (b) A health benefit issuer or pharmacy benefit manager:

     (1) Shall not refuse to authorize, approve, or pay a participating provider for providing

covered clinician-administered drugs and related services to covered persons;

     (2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an

additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other

penalty when obtaining clinician-administered drugs from a health care provider authorized under

the laws of this state to administer clinician-administered drugs, or a pharmacy;

     (3) Shall not interfere with the patient's right to choose to obtain a clinician-administered

drug from their provider or pharmacy of choice, including inducement, steering, or offering

financial or other incentives;

     (4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected

by the health plan or create such a requirement through contract with a third party, including, but

not limited to, a pharmacy benefit manager;

     (5) Shall not limit or exclude coverage for a clinician-administered drug when not

dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered;

     (6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a

pharmacy not selected by the health plan or create such an arrangement through contract with a

third party, including, but not limited to, a pharmacy benefit manager;

     (7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to

a participating provider for providing covered clinician-administered drugs and related services to

covered persons when all criteria for medical necessity are met, because the participating provider

obtains clinician-administered drugs from a pharmacy that is not a participating provider in the

health benefit issuer's network;

     (8) Shall not require that an enrollee pay an additional fee, higher copay, higher

coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-

administered drugs when not dispensed by a pharmacy selected by the health plan or create such a

requirement through contract with a third party, including, but not limited to, a pharmacy benefit

manager;

     (9) Shall not require a specialty pharmacy to dispense a clinician-administered medication

directly to a patient with the intention that the patient will transport the medication to a healthcare

provider for administration.

     (c) A health benefit issuer may offer, but shall not require, either directly or through

contract with a third party, including, but not limited to, a pharmacy benefit manager:

     (1) The use of a home infusion pharmacy to dispense clinician-administered drugs to

patients in their homes or;

     (2) The use of an infusion site external to a patient's provider office or clinic.

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

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

     27-19-26.3. Patient choice in dispensing of clinician-administered drugs.

     (a) As used in this section:

     (1) "Clinician-administered drug" means an outpatient prescription drug other than a

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vaccine that:

     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed

or by an individual assisting the patient with the self-administration; and

     (ii) Is typically administered:

     (A) By a health care provider authorized under the laws of this state to administer the drug,

including when acting under a physician's delegation and supervision; and

     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.

     (b) A health benefit issuer or pharmacy benefit manager:

     (1) Shall not refuse to authorize, approve, or pay a participating provider for providing

covered clinician-administered drugs and related services to covered persons;

     (2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an

additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other

penalty when obtaining clinician-administered drugs from a health care provider authorized under

the laws of this state to administer clinician-administered drugs, or a pharmacy;

     (3) Shall not interfere with the patient's right to choose to obtain a clinician-administered

drug from their provider or pharmacy of choice, including inducement, steering, or offering

financial or other incentives;

     (4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected

by the health plan or create such a requirement through contract with a third party, including, but

not limited to, a pharmacy benefit manager;

     (5) Shall not limit or exclude coverage for a clinician-administered drug when not

dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered;

     (6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a

pharmacy not selected by the health plan or create such an arrangement through contract with a

third party, including, but not limited to, a pharmacy benefit manager;

     (7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to

a participating provider for providing covered clinician-administered drugs and related services to

covered persons when all criteria for medical necessity are met, because the participating provider

obtains clinician-administered drugs from a pharmacy that is not a participating provider in the

health benefit issuer's network;

     (8) Shall not require that an enrollee pay an additional fee, higher copay, higher

coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-

administered drugs when not dispensed by a pharmacy selected by the health plan or create such a

requirement through contract with a third party, including, but not limited to, a pharmacy benefit

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manager;

     (9) Shall not require a specialty pharmacy to dispense a clinician-administered medication

directly to a patient with the intention that the patient will transport the medication to a healthcare

provider for administration.

     (c) A health benefit issuer may offer, but shall not require, either directly or through

contract with a third party, including, but not limited to, a pharmacy benefit manager:

     (1) The use of a home infusion pharmacy to dispense clinician-administered drugs to

patients in their homes or;

     (2) The use of an infusion site external to a patient's provider office or clinic.

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

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

     27-20-23.3. Patient choice in dispensing of clinician-administered drugs.

     (a) As used in this section:

     (1) "Clinician-administered drug" means an outpatient prescription drug other than a

vaccine that:

     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed

or by an individual assisting the patient with the self-administration; and

     (ii) Is typically administered:

     (A) By a health care provider authorized under the laws of this state to administer the drug,

including when acting under a physician's delegation and supervision; and

     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.

     (b) A health benefit issuer or pharmacy benefit manager:

     (1) Shall not refuse to authorize, approve, or pay a participating provider for providing

covered clinician-administered drugs and related services to covered persons;

     (2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an

additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other

penalty when obtaining clinician-administered drugs from a health care provider authorized under

the laws of this state to administer clinician-administered drugs, or a pharmacy;

     (3) Shall not interfere with the patient's right to choose to obtain a clinician-administered

drug from their provider or pharmacy of choice, including inducement, steering, or offering

financial or other incentives;

     (4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected

by the health plan or create such a requirement through contract with a third party, including, but

not limited to, a pharmacy benefit manager;

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     (5) Shall not limit or exclude coverage for a clinician-administered drug when not

dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered;

     (6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a

pharmacy not selected by the health plan or create such an arrangement through contract with a

third party, including, but not limited to, a pharmacy benefit manager;

     (7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to

a participating provider for providing covered clinician-administered drugs and related services to

covered persons when all criteria for medical necessity are met, because the participating provider

obtains clinician-administered drugs from a pharmacy that is not a participating provider in the

health benefit issuer's network;

     (8) Shall not require that an enrollee pay an additional fee, higher copay, higher

coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-

administered drugs when not dispensed by a pharmacy selected by the health plan or create such a

requirement through contract with a third party, including, but not limited to, a pharmacy benefit

manager;

     (9) Shall not require a specialty pharmacy to dispense a clinician-administered medication

directly to a patient with the intention that the patient will transport the medication to a healthcare

provider for administration.

     (c) A health benefit issuer may offer, but shall not require, either directly or through

contract with a third party, including, but not limited to, a pharmacy benefit manager:

     (1) The use of a home infusion pharmacy to dispense clinician-administered drugs to

patients in their homes or;

     (2) The use of an infusion site external to a patient's provider office or clinic.

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

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

     27-41-38.3. Patient choice in dispensing of clinician-administered drugs.

     (a) As used in this section:

     (1) "Clinician-administered drug" means an outpatient prescription drug other than a

vaccine that:

     (i) Cannot reasonably be self-administered by the patient to whom the drug is prescribed

or by an individual assisting the patient with the self-administration; and

     (ii) Is typically administered:

     (A) By a health care provider authorized under the laws of this state to administer the drug,

including when acting under a physician's delegation and supervision; and

LC005965 - Page 5 of 8

     (B) In a physician's office, hospital outpatient infusion center, or other clinical setting.

     (b) A health benefit issuer or pharmacy benefit manager:

     (1) Shall not refuse to authorize, approve, or pay a participating provider for providing

covered clinician-administered drugs and related services to covered persons;

     (2) Shall not impose coverage or benefits limitations, or require an enrollee to pay an

additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other

penalty when obtaining clinician-administered drugs from a health care provider authorized under

the laws of this state to administer clinician-administered drugs, or a pharmacy;

     (3) Shall not interfere with the patient's right to choose to obtain a clinician-administered

drug from their provider or pharmacy of choice, including inducement, steering, or offering

financial or other incentives;

     (4) Shall not require clinician-administered drugs to be dispensed by a pharmacy selected

by the health plan or create such a requirement through contract with a third party, including, but

not limited to, a pharmacy benefit manager;

     (5) Shall not limit or exclude coverage for a clinician-administered drug when not

dispensed by a pharmacy selected by the health plan, if the drug would otherwise be covered;

     (6) Shall not reimburse at a lesser amount clinician-administered drugs dispensed by a

pharmacy not selected by the health plan or create such an arrangement through contract with a

third party, including, but not limited to, a pharmacy benefit manager;

     (7) Shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to

a participating provider for providing covered clinician-administered drugs and related services to

covered persons when all criteria for medical necessity are met, because the participating provider

obtains clinician-administered drugs from a pharmacy that is not a participating provider in the

health benefit issuer's network;

     (8) Shall not require that an enrollee pay an additional fee, higher copay, higher

coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-

administered drugs when not dispensed by a pharmacy selected by the health plan or create such a

requirement through contract with a third party, including, but not limited to, a pharmacy benefit

manager;

     (9) Shall not require a specialty pharmacy to dispense a clinician-administered medication

directly to a patient with the intention that the patient will transport the medication to a healthcare

provider for administration.

     (c) A health benefit issuer may offer, but shall not require, either directly or through

contract with a third party, including, but not limited to, a pharmacy benefit manager:

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     (1) The use of a home infusion pharmacy to dispense clinician-administered drugs to

patients in their homes or;

     (2) The use of an infusion site external to a patient's provider office or clinic.

     SECTION 5. This act shall take effect upon passage.

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LC005965

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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 prevent healthcare entities from requiring the distribution of patient‐specific

medication from a pharmacy, typically a specialty pharmacy, to the physician's office, hospital, or

clinic for administration.

     This act would take effect upon passage.

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LC005965

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