Massachusetts 2025-2026 Regular Session

Massachusetts House Bill H1155 Compare Versions

Only one version of the bill is available at this time.

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1	1	1 of 1
2	2	HOUSE DOCKET, NO. 2005 FILED ON: 1/15/2025
3	3	HOUSE . . . . . . . . . . . . . . . No. 1155
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Michael J. Finn
8	8	_________________
9	9	To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
10	10	Court assembled:
11	11	The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
12	12	An Act empowering health care consumers.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :DATE ADDED:Michael J. Finn6th Hampden1/15/2025Natalie M. Blais1st Franklin2/25/2025James B. EldridgeMiddlesex and Worcester2/25/2025James Arciero2nd Middlesex2/25/2025 1 of 13
16	16	HOUSE DOCKET, NO. 2005 FILED ON: 1/15/2025
17	17	HOUSE . . . . . . . . . . . . . . . No. 1155
18	18	By Representative Finn of West Springfield, a petition (accompanied by bill, House, No. 1155)
19	19	of Michael J. Finn and others relative to empowering health care consumers by further regulating
20	20	policies, contracts, agreements, plans or certificates of insurance. Financial Services.
21	21	[SIMILAR MATTER FILED IN PREVIOUS SESSION
22	22	SEE HOUSE, NO. 999 OF 2023-2024.]
23	23	The Commonwealth of Massachusetts
24	24	_______________
25	25	In the One Hundred and Ninety-Fourth General Court
26	26	(2025-2026)
27	27	_______________
28	28	An Act empowering health care consumers.
29	29	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
30	30	of the same, as follows:
31	31	1 Chapter 175 of the General Laws is hereby amended by inserting after section 47II the
32	32	2following section:-
33	33	3 Section 47JJ.
34	34	4 (a) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
35	35	5renewed within the Commonwealth on or after January 1, 2018, shall:
36	36	6 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
37	37	7whether the plan uses a formulary. The notice shall include an explanation of what a formulary
38	38	8is, how the plan determines which prescription drugs are included or excluded, and how often the
39	39	9plan reviews the contents of the formulary. 2 of 13
40	40	10 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
41	41	11internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
42	42	12and providers.
43	43	13 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
44	44	14formularies within 72 hours after making the change.
45	45	15 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
46	46	16or formularies for each product offered by the plan.
47	47	17 (5) Include all of the following on any published formulary for any product offered by the
48	48	18plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
49	49	19 (i) Any prior authorization, step therapy requirements, or utilization management
50	50	20requirements for each specific drug included on the formulary.
51	51	21 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
52	52	22the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
53	53	23in the evidence of coverage.
54	54	24 (iii) For prescription drugs covered under the plans medical benefit and typically
55	55	25administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
56	56	26drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
57	57	27consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
58	58	28is staffed at least during normal business hours.
59	59	29 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
60	60	30subject to a coinsurance and dispensed at an in-network pharmacy the plan must: 3 of 13
61	61	31 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
62	62	32 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
63	63	33each specific drug included on the formulary, as follows:
64	64	34 Under $100 – $.
65	65	35 $100-$250 – $$.
66	66	36 $251-$500 – $$$.
67	67	37 $500-$1,000 – $$$$.
68	68	38 Over $1,000 -- $$$$$
69	69	39 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
70	70	40list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
71	71	41through a mail order facility utilizing the same ranges as provided in subclause (B).
72	72	42 (vi) A description of how medications will specifically be included in or excluded from
73	73	43the deductible, including a description of out-of-pocket costs that may not apply to the deductible
74	74	44for a medication.
75	75	45 (b) The Division of Insurance shall develop a standard formulary template which a health
76	76	46care service plan shall use to comply with paragraph (4).
77	77	47 SECTION 2. Chapter 176A of the General Laws is hereby amended by inserting after
78	78	48section 8KK the following section:-
79	79	49 Section 8LL. 4 of 13
80	80	50 (a) Any contract between a subscriber and the corporation under an individual or group
81	81	51hospital service plan delivered or issued or renewed within the commonwealth on or after
82	82	52January 1, 2018, shall:
83	83	53 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
84	84	54whether the plan uses a formulary. The notice shall include an explanation of what a formulary
85	85	55is, how the plan determines which prescription drugs are included or excluded, and how often the
86	86	56plan reviews the contents of the formulary.
87	87	57 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
88	88	58internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
89	89	59and providers.
90	90	60 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
91	91	61formularies within 72 hours after making the change.
92	92	62 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
93	93	63or formularies for each product offered by the plan.
94	94	64 (5) Include all of the following on any published formulary for any product offered by the
95	95	65plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
96	96	66 (i) Any prior authorization, step therapy requirements, or utilization management
97	97	67requirements for each specific drug included on the formulary.
98	98	68 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
99	99	69the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
100	100	70in the evidence of coverage. 5 of 13
101	101	71 (iii) For prescription drugs covered under the plans medical benefit and typically
102	102	72administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
103	103	73drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
104	104	74consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
105	105	75is staffed at least during normal business hours.
106	106	76 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
107	107	77subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
108	108	78 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
109	109	79 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
110	110	80each specific drug included on the formulary, as follows:
111	111	81 Under $100 – $.
112	112	82 $100-$250 – $$.
113	113	83 $251-$500 – $$$.
114	114	84 $500-$1,000 – $$$$.
115	115	85 Over $1,000 -- $$$$$
116	116	86 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
117	117	87list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
118	118	88through a mail order facility utilizing the same ranges as provided in subclause (B). 6 of 13
119	119	89 (vi) A description of how medications will specifically be included in or excluded from
120	120	90the deductible, including a description of out-of-pocket costs that may not apply to the deductible
121	121	91for a medication.
122	122	92 (b) The Division of Insurance shall develop a standard formulary template which a health
123	123	93care service plan shall use to comply with paragraph (4).
124	124	94 SECTION 3. Chapter 176B of the General Laws is hereby amended by inserting after
125	125	95section 4KK the following section:-
126	126	96 Section 4LL.
127	127	97 (a) Any subscription certificate under an individual or group medical service agreement
128	128	98delivered, issued or renewed within the commonwealth on or after January 1, 2018, shall:
129	129	99 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
130	130	100whether the plan uses a formulary. The notice shall include an explanation of what a formulary
131	131	101is, how the plan determines which prescription drugs are included or excluded, and how often the
132	132	102plan reviews the contents of the formulary.
133	133	103 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
134	134	104internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
135	135	105and providers.
136	136	106 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
137	137	107formularies within 72 hours after making the change.
138	138	108 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
139	139	109or formularies for each product offered by the plan. 7 of 13
140	140	110 (5) Include all of the following on any published formulary for any product offered by the
141	141	111plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
142	142	112 (i) Any prior authorization, step therapy requirements, or utilization management
143	143	113requirements for each specific drug included on the formulary.
144	144	114 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
145	145	115the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
146	146	116in the evidence of coverage.
147	147	117 (iii) For prescription drugs covered under the plans medical benefit and typically
148	148	118administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
149	149	119drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
150	150	120consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
151	151	121is staffed at least during normal business hours.
152	152	122 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
153	153	123subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
154	154	124 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
155	155	125 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
156	156	126each specific drug included on the formulary, as follows:
157	157	127 Under $100 – $.
158	158	128 $100-$250 – $$.
159	159	129 $251-$500 – $$$. 8 of 13
160	160	130 $500-$1,000 – $$$$.
161	161	131 Over $1,000 -- $$$$$
162	162	132 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
163	163	133list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
164	164	134through a mail order facility utilizing the same ranges as provided in subclause (B).
165	165	135 (vi) A description of how medications will specifically be included in or excluded from
166	166	136the deductible, including a description of out-of-pocket costs that may not apply to the deductible
167	167	137for a medication.
168	168	138 (b) The Division of Insurance shall develop a standard formulary template which a health
169	169	139care service plan shall use to comply with paragraph (4).
170	170	140 SECTION 4. Chapter 176G of the General Laws is hereby amended by inserting after
171	171	141section 4CC the following section:-
172	172	142 Section 4DD.
173	173	143 (a) Any individual or group health maintenance contract issued on or after January 1,
174	174	1442018, shall:
175	175	145 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
176	176	146whether the plan uses a formulary. The notice shall include an explanation of what a formulary
177	177	147is, how the plan determines which prescription drugs are included or excluded, and how often the
178	178	148plan reviews the contents of the formulary. 9 of 13
179	179	149 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
180	180	150internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
181	181	151and providers.
182	182	152 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
183	183	153formularies within 72 hours after making the change.
184	184	154 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
185	185	155or formularies for each product offered by the plan.
186	186	156 (5) Include all of the following on any published formulary for any product offered by the
187	187	157plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
188	188	158 (i) Any prior authorization, step therapy requirements, or utilization management
189	189	159requirements for each specific drug included on the formulary.
190	190	160 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
191	191	161the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
192	192	162in the evidence of coverage.
193	193	163 (iii) For prescription drugs covered under the plans medical benefit and typically
194	194	164administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
195	195	165drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
196	196	166consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
197	197	167is staffed at least during normal business hours.
198	198	168 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
199	199	169subject to a coinsurance and dispensed at an in-network pharmacy the plan must: 10 of 13
200	200	170 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
201	201	171 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
202	202	172each specific drug included on the formulary, as follows:
203	203	173 Under $100 – $.
204	204	174 $100-$250 – $$.
205	205	175 $251-$500 – $$$.
206	206	176 $500-$1,000 – $$$$.
207	207	177 Over $1,000 -- $$$$$
208	208	178 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
209	209	179list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
210	210	180through a mail order facility utilizing the same ranges as provided in subclause (B).
211	211	181 (vi) A description of how medications will specifically be included in or excluded from
212	212	182the deductible, including a description of out-of-pocket costs that may not apply to the deductible
213	213	183for a medication.
214	214	184 (b) The Division of Insurance shall develop a standard formulary template which a health
215	215	185care service plan shall use to comply with paragraph (4).
216	216	186 SECTION 5. Chapter 32A of the General Laws is hereby amended by inserting after
217	217	187section 27 the following section:-
218	218	188 Section 28. 11 of 13
219	219	189 (a) Any coverage offered by the commission to any active or retired employee of the
220	220	190commonwealth who is insured under the group insurance commission on or after January 1,
221	221	1912018, shall:
222	222	192 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
223	223	193whether the plan uses a formulary. The notice shall include an explanation of what a formulary
224	224	194is, how the plan determines which prescription drugs are included or excluded, and how often the
225	225	195plan reviews the contents of the formulary.
226	226	196 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
227	227	197internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
228	228	198and providers.
229	229	199 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
230	230	200formularies within 72 hours after making the change.
231	231	201 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
232	232	202or formularies for each product offered by the plan.
233	233	203 (5) Include all of the following on any published formulary for any product offered by the
234	234	204plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
235	235	205 (i) Any prior authorization, step therapy requirements, or utilization management
236	236	206requirements for each specific drug included on the formulary.
237	237	207 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
238	238	208the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
239	239	209in the evidence of coverage. 12 of 13
240	240	210 (iii) For prescription drugs covered under the plans medical benefit and typically
241	241	211administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
242	242	212drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
243	243	213consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
244	244	214is staffed at least during normal business hours.
245	245	215 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
246	246	216subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
247	247	217 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
248	248	218 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
249	249	219each specific drug included on the formulary, as follows:
250	250	220 Under $100 – $.
251	251	221 $100-$250 – $$.
252	252	222 $251-$500 – $$$.
253	253	223 $500-$1,000 – $$$$.
254	254	224 Over $1,000 -- $$$$$
255	255	225 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
256	256	226list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
257	257	227through a mail order facility utilizing the same ranges as provided in subclause (B). 13 of 13
258	258	228 (vi) A description of how medications will specifically be included in or excluded from
259	259	229the deductible, including a description of out-of-pocket costs that may not apply to the deductible
260	260	230for a medication.
261	261	231 (b) The Division of Insurance shall develop a standard formulary template which a health
262	262	232care service plan shall use to comply with paragraph (4).