The bill amends the General Laws by adding new definitions and clarifying terms related to prescription drug benefits. It introduces Section 27-20.8-1, which defines "cost sharing" to include copayments, coinsurance, deductibles, and annual limitations on cost sharing for healthcare services, including prescription drugs. The bill also defines "insurer," "person," and "pharmacy benefit manager" to clarify the roles of various entities involved in healthcare services and prescription drug coverage.

Additionally, the bill establishes Section 27-20.8-5, which requires 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 prescriptions that either do not have a generic equivalent or are obtained through specific processes such as prior authorization, step therapy protocols, or exceptions and appeals processes. This requirement will apply to health plans that are entered into, amended, extended, or renewed on or after January 1, 2027. The bill aims to enhance the calculation of healthcare costs for enrollees by ensuring that all relevant costs are considered.

Statutes affected:
2253: 27-20.8-1