2023 -- H 5680

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LC001837

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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 Caldwell, and Casimiro

     Date Introduced: February 17, 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:

     27-18-33.3. 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

LC001837 - 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:

LC001837 - Page 6 of 8

     (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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LC001837

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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 refusing to authorize, approve, or pay a

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

covered persons. This act would also prevent healthcare entities from imposing 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. It would prohibit interference with the patient's right to choose to obtain a

clinician-administered drug from their provider or pharmacy of choice.

     This act would take effect upon passage.

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LC001837

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