AN ACT RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES (Requires pharmacy benefit managers to provide medical justification for denying any claim for prescription drug benefits.)

H7816

2026 -- H 7816
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LC005053
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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.
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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.
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