The bill amends the General Laws by adding new definitions and clarifying existing terms related to "Prescription Drug Benefits" in Section 27-20.8-1. Key definitions introduced include "cost sharing," which encompasses copayments, coinsurance, deductibles, and annual limitations on cost sharing required by or on behalf of an enrollee for specific health care services, including prescription drugs. The terms "insurer," "person," and "pharmacy benefit manager" are also defined to clarify the roles of various entities involved in health care services.

Additionally, the bill establishes a new section, 27-20.8-5, which outlines the calculation of cost sharing for enrollees. It mandates that when calculating an enrollee's overall contribution to any out-of-pocket maximum or cost-sharing requirement under a health plan, insurers or pharmacy benefit managers must include amounts paid by the enrollee or on their behalf for prescription drugs that either do not have a generic equivalent or are accessed through specific protocols such as prior authorization, step therapy, or the health care plan's exceptions and appeals process.

The bill specifies that these cost-sharing calculations will apply to health plans that are entered into, amended, extended, or renewed on or after January 1, 2026. It also includes provisions to ensure compliance with federal law regarding Health Savings Accounts, stating that certain requirements will only apply after the enrollee has satisfied the minimum deductible for qualified High Deductible Health Plans, except for preventive care items or services. The act is set to take effect upon passage.

Statutes affected:
6209: 27-20.8-1