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H 7587Pharmaceuticals

Human Services - Medical Assistance - Prescription Drugs

This bill prohibits Medicaid from requiring prior authorization or step therapy for anticonvulsant and antipsychotic medications.

Held for study
Population
Affected
15
Email Legislator
Introduced Feb 6, 2026Committee House Finance

Plain-English Summary

This bill modifies the Rhode Island Medical Assistance Program (Medicaid) regarding coverage for specific medications. It prohibits the program and its managed care contractors from requiring "prior authorization" or "step therapy" for anticonvulsant and antipsychotic drugs. Step therapy typically requires a patient to fail on a cheaper drug before a more expensive one is covered. The legislation allows for exceptions based on safety or federal requirements. Additionally, it mandates the collection of data regarding the costs and utilization of these drugs, as well as the costs associated with mental health emergencies, with a report due in 2029.

For younger readers

Sometimes, doctors prescribe medicine to help people who have seizures or mental health challenges. Usually, insurance rules make people try a different, often cheaper, medicine first to see if it works before paying for the one the doctor actually chose. This bill changes the rules for the state's health insurance. It says that for these specific medicines, the insurance must pay for the one the doctor picked right away, without making the patient wait or try other things first. It also asks the government to keep track of how much this costs.

Who & Where It Applies

Impacted groups
Medicaid recipientsManaged Care OrganizationsDoctorsPharmacistsTaxpayers
Impacted communities
All

Constitutional & Fiscal Check

None Likely

Estimated cost
Amount unknown
Estimated revenue
None

Bill Analysis

Both viewpoints
For Progressives
  • Ensures immediate access to vital mental health and seizure medications for low-income residents, preventing gaps in treatment that can lead to severe health crises or hospitalization.
  • Eliminates bureaucratic barriers like step therapy that disproportionately harm marginalized communities who may lack the resources to navigate complex insurance appeals processes.
  • Mandates comprehensive data collection on the costs of mental health emergencies involving police and ambulances, which could provide evidence to support funding for non-carceral community care models.
  • Includes a sunset clause that repeals these protections in 2029, potentially leaving vulnerable patients without guaranteed access to their medications in the future.
  • May significantly increase costs for the state Medicaid program by removing cost-control mechanisms, potentially diverting limited funds away from other essential social safety net programs.
  • Reduces the state's leverage to negotiate lower drug prices or encourage the use of generic alternatives, effectively subsidizing pharmaceutical corporations without requiring price concessions.
For Conservatives
  • Restores medical decision-making power to physicians rather than government bureaucrats or insurance administrators regarding the prescription of specific medications.
  • Could potentially improve public safety and reduce the burden on police departments by ensuring individuals with serious mental health conditions remain stable on their prescribed medication.
  • Mandates strict reporting and data collection on spending, increasing transparency regarding how taxpayer funds are utilized within the state healthcare system.
  • Eliminates proven cost-saving mechanisms like step therapy, likely leading to bloated government spending and higher costs for taxpayers to fund the Medicaid program.
  • Creates a special market exemption for specific drug classes, preventing the state from utilizing standard free-market practices to control pharmaceutical expenses.
  • Expands the scope of government entitlement benefits without establishing a permanent funding source, potentially leading to future budget deficits.

Votes

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Full Bill Text

Changes to existing Rhode Island law · 64 additions

SECTION 1. Chapter 40-21 of the General Laws entitled "Medical Assistance — Prescription Drugs" is hereby amended by adding thereto the following section: 40-21-4. Prohibition of prior authorization or step therapy protocol.

(a) The Rhode Island medical assistance program, as defined under chapter 8 of this title, and any contract between the Rhode Island medical assistance program and a managed care organization shall not require prior authorization or a step therapy protocol for the coverage of a medication classified as an anticonvulsant or antipsychotic on their drug formulary.

(b) If the secretary of the executive office of health and human services determines that authorization from a federal agency is necessary for the implementation of this section, the secretary is authorized to seek such state plan amendment and may delay implementing the provisions until the authorization is granted.

(c) The Rhode Island medical assistance program shall require, through amending current and future medical assistance managed care contracts, that the managed care organizations meet the provisions of this section.

(d) The provisions of subsection (a) of this section do not affect clinical prior authorization edits to prescriptions of medications classified as an anticonvulsant or antipsychotic.

(e) This section does not prevent the Rhode Island medical assistance program and any contract between the Rhode Island medical assistance program and a managed care organization from denying a medication that has been removed from the market due to safety concerns from the federal Food and Drug Administration.

(f) For the purposes of this section, "step therapy protocol" means a protocol that establishes a specific sequence in which prescription medications for a specified medical condition are medically necessary for a particular enrollee and are covered under a pharmacy or medical benefit by the Rhode Island medical assistance program or a managed care organization, including self-administered and physician-administered drugs.

(g) On or before July 1, 2029, the Rhode Island medical assistance program and any managed care organization that has a contract with the Rhode Island medical assistance program shall collect and provide to the executive office of health and human services, in a form and frequency acceptable to the secretary, a report that includes the following data for the years 2021- 2029:

(1) For anticonvulsants and antipsychotics;

(i) The annual gross amount spent;

(ii) The annual net amount spent after rebates;

(iv) The average annual cost by class for generic and non-generic anticonvulsant and antipsychotic medications;

(v) The total number of anticonvulsant and antipsychotic medication claims;

(vi) The percentage of adherence to the preferred drug list ("PDL") for anticonvulsant and antipsychotic medications;

(vii) The total number of prior authorizations submitted for nonpreferred anticonvulsant and antipsychotic medications;

(viii) The total number of step therapy exceptions requested for nonpreferred anticonvulsant and antipsychotic medications;

(ix) The total number of step edits per nonpreferred anticonvulsant and antipsychotic medication;

(x) The percentages of prior authorization and step therapy approvals and denials; and

(xi) The generic anticonvulsant and generic antipsychotic medication utilization percentages.

(h) On or before July 1, 2029, the director of the department of health shall collect and provide to the executive office of health and human services, in a form and frequency acceptable to the secretary, a report that includes the following data for the years 2021-2029 from the state and from each of the thirty-nine (39) municipalities:

(1) Gross amount, non-aggregated by entity type, spent on services and personnel related to mental health emergencies performed by the following entities:

(i) Ground ambulance transport;

(ii) Air ambulance transport;

(iii) Hospitals, including inpatient and emergency departments;

(iv) Police departments; and

(v) Fire departments.

(i) On or before October 1, 2029, the executive office of health and human services shall produce and provide the information collected pursuant to subsections (g) and (h) of this section to the speaker of the house of representatives, the president of the senate, the house of representatives committee on finance, and the senate committee on health and human services.

(j) The provisions of this section shall sunset and be repealed effective December 31, 2029.

(k) This section applies to all policies, contracts, and plans executed, delivered, issued for delivery, continued or renewed in this state on or after January 1, 2027. This section shall sunset and be repealed on December 31, 2029.

SECTION 2. This act shall take effect on January 1, 2027, and shall sunset and be repealed on December 31, 2029.