2023 Rhode Island General Laws › Title 27 - Insurance › Chapter 27-41 - Health Maintenance Organizations › Section 27-41-38.3. - Specialty drugs. [Effective January 1, 2025.]

§ 27-41-38.3. Specialty drugs. [Effective January 1, 2025.]
(a)
The general assembly makes the following findings:
(1)
In 2015, an estimated six hundred thirty-five thousand (635,000) Rhode Island residents had at least one chronic disease, and an estimated two hundred forty-nine thousand (249,000) residents had two (2) or more chronic diseases, which significantly increases their likelihood to depend on prescription specialty drugs;
(2)
In 2016, twenty-five percent (25%) of Rhode Island residents stopped taking a prescription drug as prescribed due to cost;
(3)
Most specialty drugs do not have biosimilars, generic equivalents, or substitutes to create competition and help lower their prices; and
(4)
In 2022, the Centers for Medicare & Medicaid Services define any drug for which the negotiated price is six hundred seventy dollars ($670) per month or more, as a specialty drug.
(b)
As used in this section, the following words shall have the following meanings:
(1)
“Complex or chronic medical condition” means a physical, behavioral, or developmental condition that is persistent or otherwise long-lasting in its effects or a disease that advances over time, and:
(i)
May have no known cure;
(ii)
Is progressive; or
(iii)
Can be debilitating or fatal if left untreated or undertreated.
“Complex or chronic medical condition” includes, but is not limited to, multiple sclerosis, hepatitis c, and rheumatoid arthritis.
(2)
“Pre-service authorization” means a cost containment method that an insurer, a nonprofit health service plan, or a health maintenance organization uses to review and preauthorize coverage for drugs prescribed by a healthcare provider for a covered individual to control utilization, quality, and claims.
(3)
“Rare medical condition” means a disease or condition that affects fewer than:
(i)
Two hundred thousand (200,000) individuals in the United States; or
(ii)
Approximately one in one thousand five hundred (1,500) individuals worldwide.
“Rare medical condition” includes, but is not limited to, cystic fibrosis, hemophilia, and multiple myeloma.
(4)
“Specialty drug” means a prescription drug that exceeds the threshold for a specialty drug under the Medicare Part D program (Medicare Prescription Drug Improvement and Modernization Act of 2003 (Public Law 108-173)).
(5)
“Specialty drug tier” means a formulary tier in the pharmacy benefit that imposes a cost-sharing obligation for a specialty drug.
(c)
Every individual or group health insurance contract, plan, or policy that provides prescription drug coverage and is delivered, issued for delivery, or renewed in this state on or after January 1, 2025, shall limit any required copayment or coinsurance applicable to covered drugs on a specialty drug tier to an amount not to exceed one hundred fifty dollars ($150) per month for each drug up to a thirty-day (30) supply of any single drug. This limit shall be inclusive of any copayment or coinsurance. This limit shall be applicable after any deductible is reached and until the individual’s maximum out-of-pocket limit has been reached.
(d)
Nothing in this section shall prevent an entity subject to this section from reducing a covered individual’s cost sharing for a specialty drug to an amount less than that described in subsection (c) of this section.
(e)
The health insurance commissioner may promulgate any rules and regulations necessary to implement and administer this section in accordance with any federal requirements and shall use the commissioner’s enforcement powers to obtain compliance with the provisions of this section.
History of Section.
P.L. 2023, ch. 233, § 4, effective January 1, 2025.