SENATE . . . . . . . . . . . . . . No. 2637
The Commonwealth of Massachusetts
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In the One Hundred and Ninety-Third General Court
(2023-2024)
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SENATE, March 14, 2024.
The committee on Financial Services to whom was referred the petition (accompanied by
bill, Senate, No. 616) of Julian Cyr for legislation relative to patient cost, benefit and coverage
information, choice, and price transparency, report the accompanying bill (Senate, No. 2637).
For the committee,
Paul R. Feeney 1 of 6
FILED ON: 2/7/2024
SENATE . . . . . . . . . . . . . . No. 2637
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Third General Court
(2023-2024)
_______________
An Act relating to patient cost, benefit and coverage information, choice, and price transparency.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Chapter 94C of the General Laws, is hereby amended by inserting after
2section 21C the following new section:-
3 Section 21D (a) For the purposes of this section, the following terms shall have the
4following meanings unless the context clearly requires otherwise:
5 “Cost-sharing information”, the amount an enrollee is required to pay in order to receive
6a drug that is covered under the enrollee’s health plan.
7 “Enrollee” a person who is receiving a health care benefit and assumes financial
8responsibility for outstanding costs associated with a prescription drug to treat a health condition
9for themself or a dependent member of their household.
10 ''Health care benefit'', a full or partial payment for health care services or the right under a
11contract or a certificate or policy of insurance to have a full or partial payment made by a health
12plan, as defined in this section, for a specified health care service. 2 of 6
13 “Health plan” any individual, general, blanket, or group policy of health, accident or
14sickness insurance issued by an insurer licensed under chapter one hundred and seventy-five or
15the laws of any other jurisdiction, as defined by Section 1 of Chapter 176M of the Massachusetts
16General Laws.
17 “Interoperability element”, hardware, software, integrated technologies or related
18licenses, technical information, privileges, rights, intellectual property, upgrades, or services that
19may be necessary to provide the data set forth in subsection (b)(3) in the requested format and
20consistent with subsection(b)(1).
21 “Patient” the enrollee or dependent family member of the enrollee who is treated by a
22prescribing physician.
23 “Personal Representative” a person, who has been identified and authorized as a third-
24party representative by the enrollee or by the commonwealth on behalf of the enrollee, to assist
25with decision making during their medical appointment, such as: a child accompanying an
26elderly parent, a healthcare proxy, a parent of a minor child, or a spouse.
27 “Pharmacy benefit manager” (a) For the purposes of this section, the term ''pharmacy
28benefit manager'' shall mean any person or entity that administers the (i) prescription drug,
29prescription device or pharmacist services or (ii) prescription drug and device and pharmacist
30services portion of a health benefit plan on behalf of plan sponsors, including, but not limited to,
31self-insured employers, insurance companies and labor unions. A health benefit plan that does
32not contract with a pharmacy benefit manager shall be considered a pharmacy benefit manager
33for the purposes of this section, unless specifically exempted. 3 of 6
34 “Prescribing practitioner” a physician, nurse practitioner, or physician’s assistant who
35writes a prescription for a patient during the course of care for a medical condition.
36 (b) Any health plan or pharmacy benefit manager shall, upon request of the patient,
37enrollee, their prescribing practitioner, or their personal representative, furnish the cost, benefit,
38and coverage data set forth in subsection (3) to the enrollee, their prescribing practitioner, or
39their personal representative and shall ensure that such cost, benefit, and coverage data is (i)
40current as of one business day after any change is made; (ii) provided in real time to the provider
41in a clinical setting; and (iii) in the same format that the request is made by the enrollee or their
42prescribing practitioner.
43 (1) The format of the request shall use established industry content and transport
44standards published by:
45 (i) a standards developing organization accredited by the American National Standards
46Institute, included but not limited to, the National Council for Prescription Drug Programs, ASC
47X12, Health Level 7; or
48 (ii) a relevant federal or state agency or government body, included but not limited to the
49Center for Medicare & Medicaid Services or the Office of the National Coordinator for Health
50Information technology, The Commonwealth of Massachusetts Department of Public Health,
51Division of Insurance, Health Policy Commission, or Center for Health Information and
52Analysis.
53 (2) The following shall not be considered acceptable electronic formats pursuant to this
54section: 4 of 6
55 (i) a facsimile;
56 (ii) a proprietary payor or patient portal, unless it satisfies all of the requirements of
57section
58 (3) Upon such request, the following data shall be provided for any prescription drug
59covered under the enrollee’s health plan:
60 (i) the patient’s current eligibility information for such prescription drug;
61 (ii) a list of any clinically-appropriate alternatives to such prescription drug covered
62under the enrollee’s current health plan;
63 (iii) cost-sharing information for such prescription drug and such clinically-appropriate
64alternatives, including a description of any variance in cost-sharing based on pharmacy, whether
65retail or mail order, or health care provider dispensing or administering such prescription drug or
66such alternatives;
67 (iv) any applicable utilization management requirements for such prescription drug or
68such clinically-appropriate alternatives, including prior authorization, step therapy, quantity
69limits, and site-of-service restrictions
70 (4) Any health plan or pharmacy benefit manager shall furnish the data set forth in
71subsection (b)(3), whether the request is made using the prescription drug’s unique billing code,
72such as a National Drug Code or Healthcare Common Procedure Coding System code or
73descriptive term, such as the brand or generic name of the prescription drug. 5 of 6
74 (i) A health plan or pharmacy benefit manager shall not deny or delay a request as a
75method of blocking the data set forth in subsection (b)(3) from being shared based on how the
76drug was requested.
77 (c) Unless expressly prohibited by federal HIPAA law, any health plan or pharmacy
78benefit manager furnishing the data set forth in subsection (b)(3), shall not:
79 (1) restrict, prohibit, or otherwise hinder, in any way, a prescribing practitioner or health
80care professional from communicating or sharing:
81 (i) any of the data set forth in subsection (b)(3);
82 (ii) additional information on any lower-cost or clinically-appropriate alternatives,
83whether or not they are covered under the enrollee’s plan; or
84 (iii) additional payment or cost-sharing information that may reduce the patient’s out-of-
85pocket costs, such as cash price or patient assistance and support programs whether sponsored by
86a manufacturer, foundation, or other entity;
87 (2) Except as may be required by law, interfere with, prevent, or materially discourage
88access, exchange, or use of the data set forth in subsection (b)(3), which may include charging
89fees, not responding to a request at the time made where such a response is reasonably possible,
90implementing technology in nonstandard ways or instituting enrollee consent requirements,
91processes, policies, procedures, or renewals that are likely to substantially increase the
92complexity or burden of accessing, exchanging, or using such data; nor 6 of 6
93 (3) penalize a prescribing practitioner or professional for disclosing such information to
94an enrollee or their personal representative, or for prescribing, administering, or ordering a
95clinically appropriate or lower-cost alternative.
96 (4) Any health plan or pharmacy benefit manager shall treat an enrollee’s identified
97personal representative as the enrollee for purposes of this section, provided that nothing in this
98section shall expand the legal relationship between an enrollee authorized representative and
99health plan.
100 (5) If under applicable law a person has authority to act on behalf of an enrollee in
101making decisions related to health care, a health plan or pharmacy benefit manager, or its
102affiliates or entities acting on its behalf, must treat such person as a personal representative under
103this section.
104 (d) Reimbursement for fees imposed for data access pursuant to this section may be
105negotiated and contracted between a health plan or pharmacy benefit manager and a prescribing
106provider upon mutual agreement.