AN ACT RELATING TO INSURANCE -- PRESCRIPTION DRUG BENEFITS (Includes any costs paid by an enrollee or on behalf of the enrollee by a third party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost sharing requirement under a health plan as of January 1, 2027.)

H7947

2026 -- H 7947
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LC005917
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STATE OF RHODE ISLAND
IN GENERAL ASSEMBLY
JANUARY SESSION, A.D. 2026
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A N A C T
RELATING TO INSURANCE -- PRESCRIPTION DRUG BENEFITS

Introduced By:
Representatives Furtado, Casimiro, McGaw, Donovan, Alzate, Messier,
and Cruz

Date Introduced:
February 27, 2026

Referred To:
House Health & Human Services
It is enacted by the General Assembly as follows:
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SECTION 1. Sections 27-20.8-1 and 27-20.8-5 of the General Laws in Chapter 27-20.8
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entitled "Prescription Drug Benefits" is hereby amended to read as follows:
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27-20.8-1. Definitions.
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For the purposes of this chapter, the following terms shall mean:
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(1) "Cost sharing" shall mean any copayment, coinsurance, deductible, or annual limitation
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on cost sharing (including, but not limited to, a limitation subject to 42 U.S.C. §§ 18022(c) and
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300gg-6(b)), required by or on behalf of an enrollee in order to receive a specific healthcare service,
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including a prescription drug, covered by a health plan, whether covered under the medical or
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pharmacy benefit.
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(1)
(2)
“Director” shall mean the director of the department of business regulation.
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(2)
(3)
“Health plan” shall mean an insurance carrier as defined in chapters 18, 19, 20, and
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41 of this title.
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(3)
(4)
“Insured” shall mean any person who is entitled to have pharmacy services paid by
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a health plan pursuant to a policy, certificate, contract, or agreement of insurance or coverage
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including those administered for the health plan under a contract with a third-party administrator
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that manages pharmacy benefits or pharmacy network contracts.
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(5) "Insurer" shall mean any person, firm, or corporation offering and/or insuring
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healthcare services on a prepaid basis including, but not limited to, a nonprofit service corporation,
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a health maintenance organization, the Rhode Island Medicaid program, including its contracted

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managed care entities, or an entity offering a policy of accident and sickness insurance.
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(6) "Person" shall mean a natural person, corporation, mutual company, unincorporated
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association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit
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corporation, unincorporated organization, or government or governmental subdivision or agency.
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(7) "Pharmacy benefit manager" shall mean any person or business who administers the
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prescription drug or device program of one or more health plans on behalf of a third party in
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accordance with a pharmacy benefit program. This term includes any agent or representative of a
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pharmacy benefit manager hired or contracted by the pharmacy benefit manager to assist in the
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administering of the drug program and any wholly or partially owned or controlled subsidiary of a
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pharmacy benefit manager.
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27-20.8-5. Cost sharing calculation.

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(a) When calculating an enrollee’s overall contribution to any out-of-pocket maximum or
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any cost sharing requirement under a health plan, an insurer or pharmacy benefit manager shall
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include any amounts paid by the enrollee or paid on behalf of the enrollee by another person that
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is either:
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(1) Without a generic equivalent; or
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(2) With a generic equivalent where the enrollee has obtained access to the prescription
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drug through any of the following:
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(i) Prior authorization;
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(ii) A step therapy protocol; and
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(iii) The healthcare plan or carrier’s exceptions and appeals process.
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(b) If under federal law, application of subsection (a) of this section would result in Health
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Savings Account ineligibility under 26 U.S.C. § 223 (Internal Revenue Code), this requirement
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shall apply only for Health Savings Account qualified High Deductible Health Plans with respect
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to the deductible of such a plan after the enrollee has satisfied the minimum deductible under 26
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U.S.C. § 223, except for items or services that are preventive care pursuant to 26 U.S.C. §
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223(c)(2)(C) (Internal Revenue Code), in which case the requirements of subsection (a) of this
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section shall apply regardless of satisfaction of the minimum deductible under 26 U.S.C. § 223.
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(c) This section shall apply with respect to health plans that are entered into, amended,
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extended, or renewed on or after January 1, 2027.
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SECTION 3. This act shall take effect upon passage.
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EXPLANATION
BY THE LEGISLATIVE COUNCIL
OF
A N A C T
RELATING TO INSURANCE -- PRESCRIPTION DRUG BENEFITS
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This act would include any costs paid by an enrollee or on behalf of the enrollee by a third
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party when calculating an enrollee’s overall contribution to any out-of-pocket maximum or cost
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sharing requirement under a health plan as of January 1, 2027.
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This act would take effect upon passage.
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