INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES, the official text

H7816 2026 -- H 7816 ======== LC005053 ======== STATE OF RHODE ISLAND IN GENERAL ASSEMBLY JANUARY SESSION, A.D. 2026 ____________ A N A C T RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES Introduced By: Representative Charlene Lima Date Introduced: February 26, 2026 Referred To: House Health & Human Services It is enacted by the General Assembly as follows: 1 SECTION 1. Chapter 27-18 of the General Laws entitled Accident and Sickness Insurance 2 Policies is hereby amended by adding thereto the following section: 3 27-18-96. Coverage denial justification and notification. 4 (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in 5 § 27-18-33.2 shall not deny coverage for a prescription drug without first providing a written notice 6 containing a medically sound justification for the denial, delivered simultaneously to both the 7 prescribing provider and the patient. The notice shall include sufficient detail to permit the provider 8 and patient to understand the basis for denial and, if appropriate, submit an appeal or request for 9 prior authorization. 10 (1) Medical oversight requirement. Any medically sound justification required under this 11 section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health 12 care professional authorized under Rhode Island law to provide such clinical determinations, and 13 the name and license information of the reviewing professional must be included in the written 14 notice. 15 (2) Definition of medically sound justification. For purposes of this section, medically 16 sound justification means a reason based on recognized clinical standards or evidence-based 17 guidelines appropriate to the patient’s condition. 18 (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager 19 from denying coverage in accordance with the terms of the insurance plan or prescription drug 1 benefit contract; provided that, the written justification requirement and medical oversight 2 requirements are met. 3 SECTION 2. Chapter 27-19 of the General Laws entitled Nonprofit Hospital Service 4 Corporations is hereby amended by adding thereto the following section: 5 27-19-88. Coverage denial justification and notification. 6 (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in 7 § 27-19-26.2 shall not deny coverage for a prescription drug without first providing a written notice 8 containing a medically sound justification for the denial, delivered simultaneously to both the 9 prescribing provider and the patient. The notice shall include sufficient detail to permit the provider 10 and patient to understand the basis for denial and, if appropriate, submit an appeal or request for 11 prior authorization. 12 (1) Medical oversight requirement. Any medically sound justification required under this 13 section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health 14 care professional authorized under Rhode Island law to provide such clinical determinations, and 15 the name and license information of the reviewing professional must be included in the written 16 notice. 17 (2) Definition of medically sound justification. For purposes of this section, medically 18 sound justification means a reason based on recognized clinical standards or evidence-based 19 guidelines appropriate to the patient’s condition. 20 (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager 21 from denying coverage in accordance with the terms of the insurance plan or prescription drug 22 benefit contract; provided that, the written justification requirement and medical oversight 23 requirements are met. 24 SECTION 3. Chapter 27-20 of the General Laws entitled Nonprofit Medical Service 25 Corporations is hereby amended by adding thereto the following section: 26 27-20-84. Coverage denial justification and notification. 27 (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in 28 § 27-20-23.2 shall not deny coverage for a prescription drug without first providing a written notice 29 containing a medically sound justification for the denial, delivered simultaneously to both the 30 prescribing provider and the patient. The notice shall include sufficient detail to permit the provider 31 and patient to understand the basis for denial and, if appropriate, submit an appeal or request for 32 prior authorization. 33 (1) Medical oversight requirement. Any medically sound justification required under this 34 section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health LC005053 - Page 2 of 4 1 care professional authorized under Rhode Island law to provide such clinical determinations, and 2 the name and license information of the reviewing professional must be included in the written 3 notice. 4 (2) Definition of medically sound justification. For purposes of this section, medically 5 sound justification means a reason based on recognized clinical standards or evidence-based 6 guidelines appropriate to the patient’s condition. 7 (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager 8 from denying coverage in accordance with the terms of the insurance plan or prescription drug 9 benefit contract; provided that, the written justification requirement and medical oversight 10 requirements are met. 11 SECTION 4. Chapter 27-41 of the General Laws entitled Health Maintenance 12 Organizations is hereby amended by adding thereto the following section: 13 27-41-101. Coverage denial justification and notification. 14 (a) Notwithstanding any other provision of law, a pharmacy benefit manager as defined in 15 § 27-41-38.2 shall not deny coverage for a prescription drug without first providing a written notice 16 containing a medically sound justification for the denial, delivered simultaneously to both the 17 prescribing provider and the patient. The notice shall include sufficient detail to permit the provider 18 and patient to understand the basis for denial and, if appropriate, submit an appeal or request for 19 prior authorization. 20 (1) Medical oversight requirement. Any medically sound justification required under this 21 section must be provided or reviewed by a licensed physician, licensed pharmacist, or other health 22 care professional authorized under Rhode Island law to provide such clinical determinations, and 23 the name and license information of the reviewing professional must be included in the written 24 notice. 25 (2) Definition of medically sound justification. For purposes of this section, medically 26 sound justification means a reason based on recognized clinical standards or evidence-based 27 guidelines appropriate to the patient’s condition. 28 (3) Plan compliance. Nothing in this section shall prevent a pharmacy benefit manager 29 from denying coverage in accordance with the terms of the insurance plan or prescription drug 30 benefit contract; provided that, the written justification requirement and medical oversight 31 requirements are met. 32 SECTION 5. This act shall take effect on January 1, 2027. ======== LC005053 ======== LC005053 - Page 3 of 4 EXPLANATION BY THE LEGISLATIVE COUNCIL OF A N A C T RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES *** 1 This act would require pharmacy benefit managers to provide medical justification for 2 denying any claim for prescription drug benefits. 3 This act would take effect on January 1, 2027. ======== LC005053 ======== LC005053 - Page 4 of 4