2023 -- H 5350

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LC000200

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2023

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representatives Morales, Chippendale, Kislak, McNamara, Place,
Kazarian, Spears, Donovan, Potter, and Newberry

     Date Introduced: February 03, 2023

     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:

     27-18-50.2. Specialty drugs.

     (a) The general assembly makes the following findings:

     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents

had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)

residents had two (2) or more chronic diseases, which significantly increases their likelihood to

depend on prescription specialty drugs;

     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a

prescription drug as prescribed due to cost;

     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to

create competition and help lower their prices; and

     (4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the

negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.

     (b) As used in this section, the following words shall have the following meanings:

     (1) "Complex or chronic medical condition" means a physical, behavioral, or

developmental condition that is persistent or otherwise long-lasting in its effects or a disease that

advances over time, and:

     (i) May have no known cure;

     (ii) Is progressive; or

     (iii) Can be debilitating or fatal if left untreated or undertreated.

     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,

hepatitis c, and rheumatoid arthritis.

     (2) "Pre-service authorization" means a cost containment method that an insurer, a

nonprofit health service plan, or a health maintenance organization uses to review and preauthorize

coverage for drugs prescribed by a health care provider for a covered individual to control

utilization, quality, and claims.

     (3) "Rare medical condition" means a disease or condition that affects fewer than:

     (i) Two hundred thousand (200,000) individuals in the United States; or

     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.

     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and

multiple myeloma.

     (4) "Specialty drug" means a prescription drug that:

     (i) Is prescribed for an individual with a complex or chronic medical condition or a rare

medical condition; and

     (ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D

specialty tier threshold, as updated from time to time.

     (c) Every individual or group health insurance contract, plan or policy that provides

prescription coverage and is delivered, issued for delivery or renewed in this state on or after

January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty

drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty

drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage

for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a

deductible requirement would cause a health plan to not qualify as a high deductible health plan.

     (d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit

medical plan from reducing a covered individual's cost sharing to an amount less than one hundred

fifty dollars ($150) for a thirty (30)-day supply of a specialty drug.

     (e) The health insurance commissioner may promulgate any rules and regulations

necessary to implement and administer this section in accordance with any federal requirements

and shall use the commissioner's enforcement powers to obtain compliance with the provisions of

this section.

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

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

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     27-19-42.1. Specialty drugs.

     (a) The general assembly makes the following findings:

     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents

had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)

residents had two (2) or more chronic diseases, which significantly increases their likelihood to

depend on prescription specialty drugs;

     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a

prescription drug as prescribed due to cost;

     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to

create competition and help lower their prices; and

     (4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the

negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.

     (b) As used in this section, the following words shall have the following meanings:

     (1) "Complex or chronic medical condition" means a physical, behavioral, or

developmental condition that is persistent or otherwise long-lasting in its effects or a disease that

advances over time, and:

     (i) May have no known cure;

     (ii) Is progressive; or

     (iii) Can be debilitating or fatal if left untreated or undertreated.

     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,

hepatitis c, and rheumatoid arthritis.

     (2) "Pre-service authorization" means a cost containment method that an insurer, a

nonprofit health service plan, or a health maintenance organization uses to review and preauthorize

coverage for drugs prescribed by a health care provider for a covered individual to control

utilization, quality, and claims.

     (3) "Rare medical condition" means a disease or condition that affects fewer than:

     (i) Two hundred thousand (200,000) individuals in the United States; or

     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.

     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and

multiple myeloma.

     (4) "Specialty drug" means a prescription drug that:

     (i) Is prescribed for an individual with a complex or chronic medical condition or a rare

medical condition; and

     (ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D

LC000200 - Page 3 of 8

specialty tier threshold, as updated from time to time.

     (c) Every individual or group health insurance contract, plan or policy that provides

prescription coverage and is delivered, issued for delivery or renewed in this state on or after

January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty

drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty

drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage

for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a

deductible requirement would cause a health plan to not qualify as a high deductible health plan.

     (d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit

medical plan from reducing a covered individual's cost sharing to an amount less than one hundred

fifty dollars ($150) for a thirty (30)-day supply of a specialty drug.

     (e) The health insurance commissioner may promulgate any rules and regulations

necessary to implement and administer this section in accordance with any federal requirements

and shall use the commissioner's enforcement powers to obtain compliance with the provisions of

this section.

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

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

     27-20-37.1. Specialty drugs.

     (a) The general assembly makes the following findings:

     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents

had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)

residents had two (2) or more chronic diseases, which significantly increases their likelihood to

depend on prescription specialty drugs;

     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a

prescription drug as prescribed due to cost;

     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to

create competition and help lower their prices; and

     (4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the

negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.

     (b) As used in this section, the following words shall have the following meanings:

     (1) "Complex or chronic medical condition" means a physical, behavioral, or

developmental condition that is persistent or otherwise long-lasting in its effects or a disease that

advances over time, and:

     (i) May have no known cure;

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     (ii) Is progressive; or

     (iii) Can be debilitating or fatal if left untreated or undertreated.

     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,

hepatitis c, and rheumatoid arthritis.

     (2) "Pre-service authorization" means a cost containment method that an insurer, a

nonprofit health service plan, or a health maintenance organization uses to review and preauthorize

coverage for drugs prescribed by a health care provider for a covered individual to control

utilization, quality, and claims.

     (3) "Rare medical condition" means a disease or condition that affects fewer than:

     (i) Two hundred thousand (200,000) individuals in the United States; or

     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.

     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and

multiple myeloma.

     (4) "Specialty drug" means a prescription drug that:

     (i) Is prescribed for an individual with a complex or chronic medical condition or a rare

medical condition; and

     (ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D

specialty tier threshold, as updated from time to time.

     (iii) Is not typically stocked at retail pharmacies; and

     (iv)(A) Requires a difficult or unusual process of delivery to the patient in the preparation,

handling, storage, inventory, or distribution of the drug; or

     (B) Requires enhanced patient education, management, or support, beyond those required

for traditional dispensing, before or after administration of the drug.

     (c) Every individual or group health insurance contract, plan or policy that provides

prescription coverage and is delivered, issued for delivery or renewed in this state on or after

January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty

drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty

drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage

for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a

deductible requirement would cause a health plan to not qualify as a high deductible health plan.

     (d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit

medical plan from reducing a covered individual's cost sharing to an amount less than one hundred

fifty dollars ($150) for a thirty (30)-day supply of a specialty drug.

     (e) The health insurance commissioner may promulgate any rules and regulations

LC000200 - Page 5 of 8

necessary to implement and administer this section in accordance with any federal requirements

and shall use the commissioner's enforcement powers to obtain compliance with the provisions of

this section.

     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. Specialty drugs.

     (a) The general assembly makes the following findings:

     (1) In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents

had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000)

residents had two (2) or more chronic diseases, which significantly increases their likelihood to

depend on prescription specialty drugs;

     (2) In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a

prescription drug as prescribed due to cost;

     (3) Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to

create competition and help lower their prices; and

     (4) In 2022, the Centers for Medicare and Medicaid Services define any drug for which the

negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.

     (b) As used in this section, the following words shall have the following meanings:

     (1) "Complex or chronic medical condition" means a physical, behavioral, or

developmental condition that is persistent or otherwise long-lasting in its effects or a disease that

advances over time, and:

     (i) May have no known cure;

     (ii) Is progressive; or

     (iii) Can be debilitating or fatal if left untreated or undertreated.

     "Complex or chronic medical condition" includes, but is not limited to, multiple sclerosis,

hepatitis c, and rheumatoid arthritis.

     (2) "Pre-service authorization" means a cost containment method that an insurer, a

nonprofit health service plan, or a health maintenance organization uses to review and preauthorize

coverage for drugs prescribed by a health care provider for a covered individual to control

utilization, quality, and claims.

     (3) "Rare medical condition" means a disease or condition that affects fewer than:

     (i) Two hundred thousand (200,000) individuals in the United States; or

     (ii) Approximately one in one thousand five hundred (1,500) individuals worldwide.

     "Rare medical condition" includes, but is not limited to, cystic fibrosis, hemophilia, and

LC000200 - Page 6 of 8

multiple myeloma.

     (4) "Specialty drug" means a prescription drug that:

     (i) Is prescribed for an individual with a complex or chronic medical condition or a rare

medical condition; and

     (ii) Has a wholesale acquisition cost or negotiated price that exceeds the Medicare Part D

specialty tier threshold, as updated from time to time.

     (c) Every individual or group health insurance contract, plan or policy that provides

prescription coverage and is delivered, issued for delivery or renewed in this state on or after

January 1, 2024, shall not impose a copayment or coinsurance requirement on a covered specialty

drug that exceeds one hundred fifty dollars ($150) for up to a thirty (30)-day supply of the specialty

drug. A pre-service authorization may be used to provide coverage for specialty drugs. Coverage

for prescription specialty drugs shall not be subject to any deductible, unless prohibiting a

deductible requirement would cause a health plan to not qualify as a high deductible health plan.

     (d) Nothing in this section prevents an insurer, health maintenance plan, or nonprofit

medical plan from reducing a covered individual's cost sharing to an amount less than one hundred

fifty dollars ($150) for a thirty (30)-day supply of a specialty drug.

     (e) The health insurance commissioner may promulgate any rules and regulations

necessary to implement and administer this section in accordance with any federal requirements

and shall use the commissioner's enforcement powers to obtain compliance with the provisions of

this section.

     SECTION 5. This act shall take effect upon passage.

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LC000200

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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 limit the copayment or coinsurance requirement on specialty drugs to one

hundred fifty dollars ($150) for a thirty (30)-day supply regarding any specialty drug in any

individual or health insurance contract, plan or policy issued, delivered or renewed on or after

January 1, 2024. Specialty drugs would be defined as a drug prescribed to an individual with a

complex or chronic medical condition or a rare medical condition.

     This act would take effect upon passage.

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