The bill amends Section 27-20.8-1 of the General Laws regarding "Prescription Drug Benefits" by introducing new definitions and clarifying terms related to cost sharing, health plans, and pharmacy benefit managers. It defines "cost sharing" to include copayments, coinsurance, deductibles, and annual limitations required for specific healthcare services, including prescription drugs. Additionally, it introduces definitions for "insurer," "person," and "pharmacy benefit manager," expanding the scope of entities involved in administering healthcare services.

Furthermore, the bill adds a new section, 27-20.8-5, which mandates that when calculating an enrollee's overall contribution to out-of-pocket maximums or cost-sharing requirements, insurers and pharmacy benefit managers must include amounts paid by the enrollee or on their behalf for prescriptions that are either without a generic equivalent or obtained through specific processes such as prior authorization, step therapy protocols, or the health care plan's exceptions and appeals process. This requirement will apply to health plans that are entered into, amended, extended, or renewed on or after January 1, 2026, and aims to ensure that enrollees receive appropriate credit for their contributions towards their healthcare costs.

Statutes affected:
6209: 27-20.8-1