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SENATE DOCKET, NO. 375 FILED ON: 1/13/2023
SENATE . . . . . . . . . . . . . . No. 616
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
Julian Cyr
_________________
To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:
The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
An Act relating to patient cost, benefit and coverage information, choice, and price transparency.
_______________
PETITION OF:
NAME:DISTRICT/ADDRESS :Julian CyrCape and Islands 1 of 6
SENATE DOCKET, NO. 375 FILED ON: 1/13/2023
SENATE . . . . . . . . . . . . . . No. 616
By Mr. Cyr, a petition (accompanied by bill, Senate, No. 616) of Julian Cyr for legislation
relative to patient cost, benefit and coverage information, choice, and price transparency.
Financial Services.
[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE SENATE, NO. 650 OF 2021-2022.]
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Third General Court
(2023-2024)
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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. 2 of 6
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.
13 “Health plan” any insurance company authorized to provide health insurance in this state
14or any legal entity which is self-insured and providing health care benefits to its employees.
15 “Interoperability element”, hardware, software, integrated technologies or related
16licenses, technical information, privileges, rights, intellectual property, upgrades, or services that
17may be necessary to provide the data set forth in subsection (b)(3) in the requested format and
18consistent with subsection(b)(1).
19 “Patient” the enrollee or dependent family member of the enrollee who is treated by a
20prescribing physician.
21 “Personal Representative” a person, who has been identified by the enrollee or by the
22commonwealth on behalf of the enrollee, to assist with decision making during their medical
23appointment, such as: a child accompanying an elderly parent, a healthcare proxy, a parent of a
24minor child, or a spouse.
25 “Pharmacy benefit manager” (a) For the purposes of this section, the term ''pharmacy
26benefit manager'' shall mean any person or entity that administers the (i) prescription drug,
27prescription device or pharmacist services or (ii) prescription drug and device and pharmacist
28services portion of a health benefit plan on behalf of plan sponsors, including, but not limited to,
29self-insured employers, insurance companies and labor unions. A health benefit plan that does
30not contract with a pharmacy benefit manager shall be considered a pharmacy benefit manager
31for the purposes of this section, unless specifically exempted. 3 of 6
32 “Prescribing practitioner” a physician, nurse practitioner, or physician’s assistant who
33writes a prescription for a patient during the course of care for a medical condition.
34 (b) Any health plan or pharmacy benefit manager shall, upon request of the patient,
35enrollee, their prescribing practitioner, or their personal representative, furnish the cost, benefit,
36and coverage data set forth in subsection (3) to the enrollee, their prescribing practitioner, or
37their personal representative and shall ensure that such cost, benefit, and coverage data is (i)
38current as of one business day after any change is made; (ii) provided in real time; and (iii) in the
39same format that the request is made by the enrollee or their prescribing practitioner.
40 (1) The format of the request shall use established industry content and transport
41standards published by:
42 (i) a standards developing organization accredited by the American National Standards
43Institute, included but not limited to, the National Council for Prescription Drug Programs, ASC
44X12, Health Level 7; or
45 (ii) a relevant federal or state agency or government body, included but not limited to the
46Center for Medicare & Medicaid Services or the Office of the National Coordinator for Health
47Information technology, The Commonwealth of Massachusetts Department of Public Health,
48Division of Insurance, Health Policy Commission, or Center for Health Information and
49Analysis.
50 (2) A facsimile, proprietary payor or patient portal, or other electronic form other than as
51required by section (b) shall not be considered acceptable electronic formats pursuant to this
52section. 4 of 6
53 (3) Upon such request, the following data shall be provided for any prescription drug
54covered under the enrollee’s health plan:
55 (i) the patient’s current eligibility information for such prescription drug;
56 (ii) a list of any clinically-appropriate alternatives to such prescription drug covered
57under the enrollee’s current health plan;
58 (iii) cost-sharing information for such prescription drug and such clinically-appropriate
59alternatives, including a description of any variance in cost-sharing based on pharmacy, whether
60retail or mailorder, or health care provider dispensing or administering such prescription drug or
61such alternatives;
62 (iv) any applicable utilization management requirements for such prescription drug or
63such clinically-appropriate alternatives, including prior authorization, step therapy, quantity
64limits, and site-of-service restrictions
65 (4) Any health plan or pharmacy benefit manager shall furnish the data set forth in
66subsection (b)(3), whether the request is made using the prescription drug’s unique billing code,
67such as a National Drug Code or Healthcare Common Procedure Coding System code or
68descriptive term, such as the brand or generic name of the prescription drug.
69 (i) A health plan or pharmacy benefit manager shall not deny or delay a request as a
70method of blocking the data set forth in subsection (b)(3) from being shared based on how the
71drug was requested.
72 (c) Any health plan or pharmacy benefit manager furnishing the data set forth in
73subsection (b)(3), shall not: 5 of 6
74 (1) restrict, prohibit, or otherwise hinder, in any way, a prescribing practitioner or health
75care professional from communicating or sharing:
76 (i) any of the data set forth in subsection (b)(3);
77 (ii) additional information on any lower-cost or clinically-appropriate alternatives,
78whether or not they are covered under the enrollee’s plan; or
79 (iii) additional payment or cost-sharing information that may reduce the patient’s out-of-
80pocket costs, such as cash price or patient assistance and support programs whether sponsored by
81a manufacturer, foundation, or other entity;
82 (2) Except as may be required by law, interfere with, prevent, or materially discourage
83access, exchange, or use of the data set forth in subsection (b)(3), which may include charging
84fees, not responding to a request at the time made where such a response is reasonably possible,
85implementing technology in nonstandard ways or instituting enrollee consent requirements,
86processes, policies, procedures, or renewals that are likely to substantially increase the
87complexity or burden of accessing, exchanging, or using such data; nor
88 (3) penalize a prescribing practitioner or professional for disclosing such information to
89an enrollee or their personal representative, or for prescribing, administering, or ordering a
90clinically appropriate or lower-cost alternative.
91 (4) Any health plan or pharmacy benefit manager shall treat an enrollee’s identified
92personal representative as the enrollee for purposes of this section.
93 (5) If under applicable law a person has authority to act on behalf of an enrollee in
94making decisions related to health care, a health plan or pharmacy benefit manager, or its 6 of 6
95affiliates or entities acting on its behalf, must treat such person as a personal representative under
96this section.
97 (d) Reimbursement for fees imposed for data access pursuant to this section may be
98negotiated and contracted between a health plan or pharmacy benefit manager and a prescribing
99provider upon mutual agreement