2023 -- H 5680

========

LC001837

========

     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2023

____________

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:

1

     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance

2

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

3

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

4

     (a) As used in this section:

5

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

6

vaccine that:

7

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

8

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

9

     (ii) Is typically administered:

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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

 

1

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

2

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

3

financial or other incentives;

4

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

5

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

6

not limited to, a pharmacy benefit manager;

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

16

health benefit issuer's network;

17

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

18

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

19

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

20

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

21

manager;

22

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

23

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

24

provider for administration.

25

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

26

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

27

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

28

patients in their homes or;

29

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

30

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

31

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

32

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

33

     (a) As used in this section:

34

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

 

LC001837 - Page 2 of 8

1

vaccine that:

2

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

3

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

4

     (ii) Is typically administered:

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

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

16

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

17

financial or other incentives;

18

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

19

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

20

not limited to, a pharmacy benefit manager;

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

health benefit issuer's network;

31

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

32

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

33

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

34

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

 

LC001837 - Page 3 of 8

1

manager;

2

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

3

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

4

provider for administration.

5

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

6

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

7

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

8

patients in their homes or;

9

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

10

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

11

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

12

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

13

     (a) As used in this section:

14

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

15

vaccine that:

16

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

17

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

18

     (ii) Is typically administered:

19

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

20

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

21

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

22

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

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

31

financial or other incentives;

32

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

33

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

34

not limited to, a pharmacy benefit manager;

 

LC001837 - Page 4 of 8

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

10

health benefit issuer's network;

11

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

12

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

13

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

14

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

15

manager;

16

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

17

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

18

provider for administration.

19

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

20

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

21

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

22

patients in their homes or;

23

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

24

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

25

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

26

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

27

     (a) As used in this section:

28

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

29

vaccine that:

30

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

31

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

32

     (ii) Is typically administered:

33

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

34

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

 

LC001837 - Page 5 of 8

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

financial or other incentives;

12

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

13

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

14

not limited to, a pharmacy benefit manager;

15

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

16

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

17

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

18

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

19

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

20

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

21

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

22

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

23

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

24

health benefit issuer's network;

25

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

26

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

27

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

28

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

29

manager;

30

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

31

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

32

provider for administration.

33

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

34

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

 

LC001837 - Page 6 of 8

1

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

2

patients in their homes or;

3

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

4

     SECTION 5. This act shall take effect upon passage.

========

LC001837

========

 

LC001837 - Page 7 of 8

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

1

     This act would prevent healthcare entities from refusing to authorize, approve, or pay a

2

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

3

covered persons. This act would also prevent healthcare entities from imposing coverage or benefits

4

limitations, or require an enrollee to pay an additional fee, higher copay, higher coinsurance, second

5

copay, second coinsurance, or other penalty when obtaining clinician-administered drugs from a

6

health care provider. It would prohibit interference with the patient's right to choose to obtain a

7

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

8

     This act would take effect upon passage.

========

LC001837

========

 

LC001837 - Page 8 of 8