SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness Insurance Policies" is hereby amended by adding thereto the following section: 27-18-50.3. Prescription hormone therapy.
(a) As used in this section, "prescription hormone therapy" means all drugs approved by the United States Food and Drug Administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels, as determined by the prescribing provider. Prescription hormone therapy includes, but is not limited to, any necessary supplies for administration. Prescription hormone therapy shall not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.
(b) Beginning on the first day of each plan year after January 1, 2027, every individual or group health insurance contract, plan, or policy that provides prescription hormone therapy coverage and is delivered, issued for delivery, or renewed in this state shall provide reimbursement for dispensing covered prescription hormone therapy up to three hundred sixty-five (365) days at one time, unless the enrollee requests a smaller supply, the prescribing provider instructs that the enrollee shall receive a smaller supply, or the prescription hormone therapy is a controlled substance. If the prescription hormone therapy is a controlled substance, the health plan shall provide reimbursement for the maximum refill allowed under state and federal law to be obtained at one time by the enrollee.
(c) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a three hundred sixty-five (365) day supply of the prescription hormone therapy has already been dispensed during the plan year.
(d) To the extent not otherwise prohibited under this section or state or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under subsection (a) of this section.
(e) This section does not apply to insurance coverage providing benefits for:
(1) Hospital confinement indemnity;
(2) Disability income;
(3) Accident only;
(4) Long-term care;
(5) Medicare supplement;
(6) Limited benefit health;
(7) Specified disease indemnity;
(8) Sickness or bodily injury or death by accident or both; and
(9) Other limited-benefit policies.
SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service Corporations" is hereby amended by adding thereto the following section: 27-19-42.2. Prescription hormone therapy.
(a) As used in this section, "prescription hormone therapy" means all drugs approved by the United States Food and Drug Administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels, as determined by the prescribing provider. Prescription hormone therapy includes, but is not limited to, any necessary supplies for administration. Prescription hormone therapy shall not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.
(b) Beginning on the first day of each plan year after January 1, 2027, every individual or group health insurance contract, plan, or policy that provides prescription hormone therapy coverage and is delivered, issued for delivery, or renewed in this state shall provide reimbursement for dispensing covered prescription hormone therapy up to three hundred sixty-five (365) days at one time, unless the enrollee requests a smaller supply, the prescribing provider instructs that the enrollee shall receive a smaller supply, or the prescription hormone therapy is a controlled substance. If the prescription hormone therapy is a controlled substance, the health plan shall provide reimbursement for the maximum refill allowed under state and federal law to be obtained at one time by the enrollee.
(c) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a three hundred sixty-five (365) day supply of the prescription hormone therapy has already been dispensed during the plan year.
(d) To the extent not otherwise prohibited under this section or state or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under subsection (a) of this section.
(e) This section does not apply to insurance coverage providing benefits for:
(1) Hospital confinement indemnity;
(2) Disability income;
(3) Accident only;
(4) Long-term care;
(5) Medicare supplement;
(6) Limited benefit health;
(7) Specified disease indemnity;
(8) Sickness or bodily injury or death by accident or both; and
(9) Other limited-benefit policies.
SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service Corporations" is hereby amended by adding thereto the following section: 27-20-23.4. Prescription hormone therapy.
(a) As used in this section, "prescription hormone therapy" means all drugs approved by the United States Food and Drug Administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels, as determined by the prescribing provider. Prescription hormone therapy includes, but is not limited to, any necessary supplies for administration. Prescription hormone therapy shall not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.
(b) Beginning on the first day of each plan year after January 1, 2027, every individual or group health insurance contract, plan, or policy that provides prescription hormone therapy coverage and is delivered, issued for delivery, or renewed in this state shall provide reimbursement for dispensing covered prescription hormone therapy up to three hundred sixty-five (365) days at one time, unless the enrollee requests a smaller supply, the prescribing provider instructs that the enrollee shall receive a smaller supply, or the prescription hormone therapy is a controlled substance. If the prescription hormone therapy is a controlled substance, the health plan shall provide reimbursement for the maximum refill allowed under state and federal law to be obtained at one time by the enrollee.
(c) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a three hundred sixty-five (365) day supply of the prescription hormone therapy has already been dispensed during the plan year.
(d) To the extent not otherwise prohibited under this section or state or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under subsection (a) of this section.
(e) This section does not apply to insurance coverage providing benefits for:
(1) Hospital confinement indemnity;
(2) Disability income;
(3) Accident only;
(4) Long-term care;
(5) Medicare supplement;
(6) Limited benefit health;
(7) Specified disease indemnity;
(8) Sickness or bodily injury or death by accident or both; and
(9) Other limited-benefit policies.
SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance Organizations" is hereby amended by adding thereto the following section: 27-41-38.5. Prescription hormone therapy.
(a) As used in this section, "prescription hormone therapy" means all drugs approved by the United States Food and Drug Administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels, as determined by the prescribing provider. Prescription hormone therapy includes, but is not limited to, any necessary supplies for administration. Prescription hormone therapy shall not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.
(b) Beginning on the first day of each plan year after January 1, 2027, every individual or group health insurance contract, plan, or policy that provides prescription hormone therapy coverage and is delivered, issued for delivery, or renewed in this state shall provide reimbursement for dispensing covered prescription hormone therapy up to three hundred sixty-five (365) days at one time, unless the enrollee requests a smaller supply, the prescribing provider instructs that the enrollee shall receive a smaller supply, or the prescription hormone therapy is a controlled substance. If the prescription hormone therapy is a controlled substance, the health plan shall provide reimbursement for the maximum refill allowed under state and federal law to be obtained at one time by the enrollee.
(c) Nothing in this section prohibits a health plan from limiting refills that may be obtained in the last quarter of the plan year if a three hundred sixty-five (365) day supply of the prescription hormone therapy has already been dispensed during the plan year.
(d) To the extent not otherwise prohibited under this section or state or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under subsection (a) of this section.
(e) This section does not apply to insurance coverage providing benefits for:
(1) Hospital confinement indemnity;
(2) Disability income;
(3) Accident only;
(4) Long-term care;
(5) Medicare supplement;
(6) Limited benefit health;
(7) Specified disease indemnity;
(8) Sickness or bodily injury or death by accident or both; and
(9) Other limited-benefit policies.
SECTION 5. Chapter 40-8.4 of the General Laws entitled "Health Care for Families" is hereby amended by adding thereto the following section: 40-8.4-21. Prescription hormone therapy.
(a) As used in this section, "prescription hormone therapy" means all drugs approved by the United States food and drug administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels, as determined by the prescribing provider. Prescription hormone therapy includes, but is not limited to, any necessary supplies for administration. Prescription hormone therapy does not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.
(b) Beginning January 1, 2027, the executive office of health and human services (EOHHS) shall provide Medicaid beneficiaries who are prescribed prescription hormone therapy up to three hundred sixty-five (365) days of prescription hormone therapy dispensed as a single prescription.
(c) The secretary of the EOHHS shall apply to the United States department of health and human services for any amendment to the state Medicaid plan or for any Medicaid waiver as necessary to implement this section. The secretary of the EOHHS shall submit the Medicaid state plan amendment within ninety (90) days of the effective date of this section.
SECTION 6. This act shall take effect upon passage.
