Drug benefit managers must share records and follow patient protections

Drug benefit managers must allow pharmacies to discuss prices and alternatives, limit copayments, and follow restrictions on changing prescriptions. The disclosure and copayment rules apply to managers’ contracts with pharmacies or agents that negotiate for pharmacies. A manager may change a prescribed drug or prescription terms with the prescriber’s approval or when law explicitly permits or requires it. Managers may not prohibit or punish pharmacies for sharing costs, pharmacy payments, equivalent medicines, or other ways to buy a prescription. A copayment cannot exceed the pharmacy’s submitted charges for which it is paid. When a patient pays a copayment, the pharmacy keeps the approved claim amount, and the manager cannot take it back. These provisions take effect January 1, 2027.

Drug benefit managers must provide pharmacies a process to challenge payment limits for generic drugs available from multiple suppliers. The process covers contracts with pharmacies or their negotiating agents and disputes over the maximum amount paid for these generic drugs. Pharmacies or their negotiating agents must appeal within 15 days following the initial payment claim. Managers must acknowledge receipt by email and send a decision within 15 days. A successful appeal corrects the appealing pharmacy’s payment limit back to the original claim date. The pharmacy must cancel and resubmit that claim to receive the corrected payment. If a wider correction is warranted, similarly situated pharmacies in the manager’s Rhode Island network must receive it no later than one day after the successful appeal decision. A denial must explain the reason and identify an equivalent drug available in adequate supply from wholesalers at or below the payment limit. These appeal requirements take effect January 1, 2027.

Drug benefit managers must work carefully, deal fairly, and hold service-related money in trust, using it only as their insurer contract or law allows. These duties cover managing prescription benefits and dealings with covered people, pharmacies, and other parties. Managers owe people with prescription coverage the same duty as the insurer they serve. Money-use limits include fees expressly allowed by the insurer contract and money from spread pricing, which means charging more for a drug than the manager pays the pharmacy. These duties and money-handling requirements take effect January 1, 2027.

Drug benefit managers must give insurers financial records, related contract terms, and information about conflicts of interest. Each insurer receives information about services provided to it, including financial benefits, pharmacy fees, and arrangements that conflict with the manager’s duties to that insurer. Insurers must protect information reasonably marked as confidential business information or trade secrets, except when law permits or requires disclosure. Confidential labels do not remove duties to give records to the health insurance commissioner. Those protected records remain confidential at the commissioner’s office. Beginning August 1, 2028, reports required under the Consolidated Appropriation Act of 2026 and later regulations count toward compliance. The clause does not clearly identify which reporting requirements they satisfy. Disclosure to insurers begins August 1, 2027. The confidentiality provisions take effect January 1, 2027.

Rhode Island’s health insurance commissioner must oversee these requirements, issue rules, and report how drug benefit managers affect insurance costs. Managers are regulated under Chapter 84. The study concerns their practices and operations and their effects on Rhode Island health insurance costs. Insurers must show the commissioner their willingness and potential ability to provide accessible pharmacy services with adequate staff and facilities. Managers or insurers under investigation, examination, or enforcement must share enforcement costs equally. Costs include 150% of enforcement staff salaries and benefits, less salary reimbursements, plus reasonable technology, training, and outside expert expenses. The law takes effect January 1, 2027. The commissioner must send findings and recommendations to the General Assembly on or before March 31, 2027.