2023 -- S 0799

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LC002404

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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 -- PRESCRIPTION DRUG BENEFITS

     

     Introduced By: Senators Goodwin, and Miller

     Date Introduced: March 23, 2023

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Section 27-20.8-1 of the General Laws in Chapter 27-20.8 entitled

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"Prescription Drug Benefits" is hereby amended to read as follows:

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     27-20.8-1. Definitions.

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     For the purposes of this chapter, the following terms shall mean:

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     (1) "Cost sharing" means any copayment, coinsurance, deductible, or annual limitation on

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cost sharing (including, but not limited to, a limitation subject to 42 U.S.C. §§ 18022(c) and 300gg-

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6(b)), required by or on behalf of an enrollee in order to receive a specific health care service,

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including a prescription drug, covered by a health plan, whether covered under the medical or

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pharmacy benefit.

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     (2) "Director" shall mean the director of the department of business regulation.

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     (2)(3) "Health plan" shall mean an insurance carrier as defined in chapters 18, 19, 20 and

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41 of this title.

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     (3)(4) "Insured" shall mean any person who is entitled to have pharmacy services paid by

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a health plan pursuant to a policy, certificate, contract or agreement of insurance or coverage

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including those administered for the health plan under a contract with a third-party administrator

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that manages pharmacy benefits or pharmacy network contracts.

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     (5) "Insurer" means any person, firm, or corporation offering and/or insuring healthcare

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services on a prepaid basis, including, but not limited to, a nonprofit service corporation, a health

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maintenance organization, the Rhode Island Medicaid program, including its contracted managed

 

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care entities, or an entity offering a policy of accident and sickness insurance.

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     (6) "Person" means a natural person, corporation, mutual company, unincorporated

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association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit

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corporation, unincorporated organization, or government or governmental subdivision or agency.

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     (7) "Pharmacy benefit manager" means, any person or business who administers the

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prescription drug or device program of one or more health plans on behalf of a third party in

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accordance with a pharmacy benefit program. This term includes any agent or representative of a

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pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the

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administering of the drug program and any wholly or partially owned or controlled subsidiary of a

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pharmacy benefit manager.

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     SECTION 2. Chapter 27-20.8 of the General Laws entitled "Prescription Drug Benefits" is

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hereby amended by adding thereto the following section:

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     27-20.8-5. Cost sharing calculation.

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     (a) When calculating an enrollee's overall contribution to any out-of-pocket maximum or

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any cost sharing requirement under a health plan, an insurer or pharmacy benefit manager shall

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include any amounts paid by the enrollee or paid on behalf of the enrollee by another person.

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     (b) This section shall apply with respect to health plans that are entered into, amended,

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extended, or renewed on or after January 1, 2024.

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     SECTION 3. This act shall take effect upon passage.

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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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     This act would include any costs paid by an enrollee or on behalf of the enrollee by a third

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party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost

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sharing requirement under a health plan as of January 1, 2024.

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     This act would take effect upon passage.

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