SECTION 1. Section 27-20.8-1 of the General Laws in Chapter 27-20.8 entitled "Prescription Drug Benefits" is hereby amended to read as follows: 27-20.8-1. Definitions. For the purposes of this chapter, the following terms shall mean:
(1) “Cost sharing” shall mean any copayment, coinsurance, deductible, or annual limitation on cost sharing including, but not limited to, a limitation subject to 42 U.S.C. §§ 18022(c) and 300gg-6(b), required by or on behalf of an enrollee in order to receive a specific healthcare service, including a prescription drug, covered by a health plan, whether covered under the medical or pharmacy benefit. (1)(2) “Director” shall mean the director of the department of business regulation. (2)(3) “Health plan” shall mean an insurance carrier as defined in chapters 18, 19, 20, and 41 of this title. (3)(4) “Insured” shall mean any person who is entitled to have pharmacy services paid by a health plan pursuant to a policy, certificate, contract, or agreement of insurance or coverage including those administered for the health plan under a contract with a third-party administrator that manages pharmacy benefits or pharmacy network contracts.
(5) “Insurer” shall mean any person, firm, or corporation offering and/or insuring healthcare services on a prepaid basis, including, but not limited to, a nonprofit service corporation, a health maintenance organization, the Rhode Island Medicaid program, including its contracted managed care entities, or an entity offering a policy of accident and sickness insurance.
(6) “Person” shall mean a natural person, corporation, mutual company, unincorporated association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit corporation, unincorporated organization, or government or governmental subdivision or agency.
(7) “Pharmacy benefit manager” shall mean any person or business, who administers the prescription drug or device program of one or more health plans on behalf of a third party, in accordance with a pharmacy benefit program. This term includes any agent or representative of a pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the administering of the drug program and any wholly or partially owned or controlled subsidiary of a pharmacy benefit manager.
SECTION 2. Chapter 27-20.8 of the General Laws entitled "Prescription Drug Benefits" is hereby amended by adding thereto the following section: 27-20.8-5. Cost sharing calculation.
(a) When calculating an enrollee’s overall contribution to any out-of-pocket maximum or any cost sharing requirement under a health plan, an insurer or pharmacy benefit manager shall include any amounts paid by the enrollee or paid on behalf of the enrollee by another person that is either:
(1) Without a generic equivalent; or
(2) With a generic equivalent, where the enrollee has obtained access to the prescription drug through any of the following:
(i) Prior authorization;
(ii) A step therapy protocol; or
(iii) The healthcare plan or carrier’s exceptions and appeals process.
(b) If under federal law, application of subsection (a) of this section would result in Health Savings Account ineligibility under § 223 of the federal Internal Revenue Code ("IRC"), this requirement shall apply only for Health Savings Account qualified High Deductible Health Plans with respect to the deductible of such a plan after the enrollee has satisfied the minimum deductible under § 223, except for items or services that are preventive care pursuant to § 223(c)(2)(C) of the federal Internal Revenue Code, in which case the requirements of subsection (a) of this section shall apply regardless of satisfaction of the minimum deductible under § 223 of the IRC.
(c) This section shall apply with respect to health plans that are entered into, amended, extended, or renewed on or after January 1, 2027.
SECTION 3. This act shall take effect upon passage.
