SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance Policies" is hereby amended by adding thereto the following section: 27-18-96. Coverage denial justification and notification.
(a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in § 27-18-33.2 shall not deny coverage for a prescription drug without first providing a written notice containing a medically sound justification for the denial, delivered simultaneously to both the prescribing provider and the patient. The notice shall include sufficient detail to permit the provider and patient to understand the basis for denial and, if appropriate, submit an appeal or request for prior authorization.
(1) Medical oversight requirement. Any medically sound justification required under this section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health care professional authorized under Rhode Island law to provide such clinical determinations, and the name and license information of the reviewing professional must be included in the written notice.
(2) Definition of medically sound justification. For purposes of this section, "medically sound justification" means a reason based on recognized clinical standards or evidence-based guidelines appropriate to the patient’s condition.
(3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager from denying coverage in accordance with the terms of the insurance plan or prescription drug benefit contract; provided that, the written justification requirement and medical oversight requirements are met.
SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service Corporations" is hereby amended by adding thereto the following section: 27-19-88. Coverage denial justification and notification.
(a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in § 27-19-26.2 shall not deny coverage for a prescription drug without first providing a written notice containing a medically sound justification for the denial, delivered simultaneously to both the prescribing provider and the patient. The notice shall include sufficient detail to permit the provider and patient to understand the basis for denial and, if appropriate, submit an appeal or request for prior authorization.
(1) Medical oversight requirement. Any medically sound justification required under this section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health care professional authorized under Rhode Island law to provide such clinical determinations, and the name and license information of the reviewing professional must be included in the written notice.
(2) Definition of medically sound justification. For purposes of this section, "medically sound justification" means a reason based on recognized clinical standards or evidence-based guidelines appropriate to the patient’s condition.
(3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager from denying coverage in accordance with the terms of the insurance plan or prescription drug benefit contract; provided that, the written justification requirement and medical oversight requirements are met.
SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service Corporations" is hereby amended by adding thereto the following section: 27-20-84. Coverage denial justification and notification.
(a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in § 27-20-23.2 shall not deny coverage for a prescription drug without first providing a written notice containing a medically sound justification for the denial, delivered simultaneously to both the prescribing provider and the patient. The notice shall include sufficient detail to permit the provider and patient to understand the basis for denial and, if appropriate, submit an appeal or request for prior authorization.
(1) Medical oversight requirement. Any medically sound justification required under this section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health care professional authorized under Rhode Island law to provide such clinical determinations, and the name and license information of the reviewing professional must be included in the written notice.
(2) Definition of medically sound justification. For purposes of this section, "medically sound justification" means a reason based on recognized clinical standards or evidence-based guidelines appropriate to the patient’s condition.
(3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager from denying coverage in accordance with the terms of the insurance plan or prescription drug benefit contract; provided that, the written justification requirement and medical oversight requirements are met.
SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance Organizations" is hereby amended by adding thereto the following section: 27-41-101. Coverage denial justification and notification.
(a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in § 27-41-38.2 shall not deny coverage for a prescription drug without first providing a written notice containing a medically sound justification for the denial, delivered simultaneously to both the prescribing provider and the patient. The notice shall include sufficient detail to permit the provider and patient to understand the basis for denial and, if appropriate, submit an appeal or request for prior authorization.
(1) Medical oversight requirement. Any medically sound justification required under this section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health care professional authorized under Rhode Island law to provide such clinical determinations, and the name and license information of the reviewing professional must be included in the written notice.
(2) Definition of medically sound justification. For purposes of this section, "medically sound justification" means a reason based on recognized clinical standards or evidence-based guidelines appropriate to the patient’s condition.
(3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager from denying coverage in accordance with the terms of the insurance plan or prescription drug benefit contract; provided that, the written justification requirement and medical oversight requirements are met.
SECTION 5. This act shall take effect on January 1, 2027.
