The bill amends Section 27-20.8-1 of the General Laws regarding "Prescription Drug Benefits" by introducing new definitions and clarifications. Key insertions include definitions for terms such as "cost sharing," "insurer," "person," and "pharmacy benefit manager." The bill specifies that "cost sharing" encompasses any copayment, coinsurance, deductible, or annual limitation required for receiving healthcare services, including prescription drugs.

Additionally, the bill establishes that when calculating an enrollee's overall contribution to out-of-pocket maximums or cost-sharing requirements under a health plan, insurers and pharmacy benefit managers must include any amounts paid by the enrollee or on their behalf. This includes cases where a generic equivalent is not available or when the enrollee has accessed the prescription drug through prior authorization, a step therapy protocol, or the health care plan's exceptions and appeals process.

The bill adds a new section, 27-20.8-5, which outlines the calculation of cost sharing for health plans, effective January 1, 2026. It stipulates that if the application of these provisions would result in Health Savings Account ineligibility under federal law, the requirement will only apply to Health Savings Account qualified High Deductible Health Plans concerning the deductible after the enrollee has satisfied the minimum deductible, except for preventive care items or services. Overall, this legislation aims to enhance the calculation of prescription drug costs for enrollees.

Statutes affected:
477: 27-20.8-1