RI H7816

Pharmacy benefit managers (PBMs) must provide written notice with a medically sound justification before denying coverage for any prescription drug, delivered simultaneously to both the prescribing provider and the patient.

All denial justifications must be provided or reviewed by a licensed physician, pharmacist, or other authorized healthcare professional, with the reviewer's name and license information included in the notice.

"Medically sound justification" is defined as a reason based on recognized clinical standards or evidence-based guidelines appropriate to the patient's condition.

The requirements apply across four categories of insurers: accident and sickness insurance policies, nonprofit hospital service corporations, nonprofit medical service corporations, and health maintenance organizations.

The act takes effect January 1, 2027.