The bill amends Chapter 27-20.8 entitled "Prescription Drug Benefits" in the General Laws to redefine and expand certain definitions and to establish how cost sharing is calculated for enrollees in health plans. New definitions are added for "cost sharing," "insurer," "person," and "pharmacy benefit manager," clarifying the terms used within the context of the chapter. The definition of "cost sharing" now includes any copayment, coinsurance, deductible, or annual limitation on cost sharing required by or on behalf of an enrollee for receiving a specific health care service, including prescription drugs. The term "insurer" is defined to include various entities offering and insuring healthcare services, and "pharmacy benefit manager" is defined as a person or business administering the prescription drug program of health plans.

The bill also introduces a new section, 27-20.8-5, titled "Cost sharing calculation," which mandates that when calculating an enrollee's contribution to any out-of-pocket maximum or cost sharing requirement under a health plan, the insurer or pharmacy benefit manager must include any amounts paid by the enrollee or on behalf of the enrollee by another person. This provision is set to apply to health plans that are entered into, amended, extended, or renewed on or after January 1, 2024. The act will take effect upon passage, ensuring that all costs paid by or for the enrollee are accounted for in the calculation of out-of-pocket expenses.

Statutes affected:
6159: 27-20.8-1