Massachusetts 2025-2026 Regular Session

Massachusetts House Bill H1325 Compare Versions

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

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2	2	HOUSE DOCKET, NO. 2356 FILED ON: 1/16/2025
3	3	HOUSE . . . . . . . . . . . . . . . No. 1325
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Alan Silvia
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 to ensure access to generic medication.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :DATE ADDED:Alan Silvia7th Bristol1/16/2025 1 of 6
16	16	HOUSE DOCKET, NO. 2356 FILED ON: 1/16/2025
17	17	HOUSE . . . . . . . . . . . . . . . No. 1325
18	18	By Representative Silvia of Fall River, a petition (accompanied by bill, House, No. 1325) of
19	19	Alan Silvia relative to access to generic medications. Financial Services.
20	20	[SIMILAR MATTER FILED IN PREVIOUS SESSION
21	21	SEE HOUSE, NO. 1150 OF 2023-2024.]
22	22	The Commonwealth of Massachusetts
23	23	_______________
24	24	In the One Hundred and Ninety-Fourth General Court
25	25	(2025-2026)
26	26	_______________
27	27	An Act to ensure access to generic medication.
28	28	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
29	29	of the same, as follows:
30	30	1 Chapter 176D is hereby amended by adding, after section 3B, the following section:-
31	31	2 Section 3C. (a) For the purposes of this section the term "maximum allowable cost list"
32	32	3shall mean a list of drugs, medical products or devices, or both medical products and devices, for
33	33	4which a maximum allowable cost has been established by a pharmacy benefits manager or
34	34	5covered entity. The term "maximum allowable cost" shall mean the maximum amount that a
35	35	6pharmacy benefits manager or covered entity will reimburse a pharmacy for the cost of a drug or
36	36	7a medical product or device.
37	37	8 (b) Before a pharmacy benefits manager or covered entity may place a drug on a
38	38	9maximum allowable cost list the drug must be listed as "A" or "AB" rated in the most recent
39	39	10version of the FDA's Approved Drug Products with Therapeutic Equivalence Evaluations, also 2 of 6
40	40	11known as the Orange Book, or has an "NR" or "NA" rating or a similar rating by a nationally
41	41	12recognized reference; and that there are at least two therapeutically equivalent, multiple source
42	42	13drugs, or at least one generic drug available from one manufacturer, available for purchase by
43	43	14network pharmacies from national or regional wholesalers.
44	44	15 (c) If a drug that has been placed on a maximum allowable cost list no longer meets the
45	45	16requirements of subsection (a), the drug shall be removed from the maximum allowable cost list
46	46	17by the pharmacy benefits manager or covered entity within 3 business days after the drug no
47	47	18longer meets the requirements of subsection (a).
48	48	19 (d) A pharmacy benefits manager or covered entity shall make available to each
49	49	20pharmacy with which the pharmacy benefits manager or covered entity has a contract and to
50	50	21each pharmacy included in a network of pharmacies served by a pharmacy services
51	51	22administrative organization with which the pharmacy benefits manager or covered entity has a
52	52	23contract, at the beginning of the term of a contract upon renewal of a contract, or upon request:
53	53	24 (1) The sources used to determine the maximum allowable costs for the drugs and
54	54	25medical products and devices on each maximum allowable cost list;
55	55	26 (2) Every maximum allowable cost for individual drugs used by that pharmacy benefits
56	56	27manager or covered entity for patients served by that contracted pharmacy; and
57	57	28 (3) Upon request, every maximum allowable cost list used by that pharmacy benefits
58	58	29manager or covered entity for patients served by that contracted pharmacy.
59	59	30 (e) A pharmacy benefits manager or covered entity shall: 3 of 6
60	60	31 (1) Ensure the maxim allowable cost is equal to or greater than the pharmacies
61	61	32acquisition cost and update each maximum allowable cost list at least every 3 business days;
62	62	33 (2) Make the updated lists available to every pharmacy with which the pharmacy benefits
63	63	34manager or covered entity has a contract and to every pharmacy included in a network of
64	64	35pharmacies served by a pharmacy services administrative organization with which the pharmacy
65	65	36benefits manager or covered entity has a contract, in a readily accessible, secure and usable web-
66	66	37based format or other comparable format or process; and
67	67	38 (3) Utilize the updated maximum allowable costs to calculate the payments made to the
68	68	39contracted pharmacies within 2 business days.
69	69	40 (f) A pharmacy benefits manager or covered entity shall establish a clearly defined
70	70	41process through which a pharmacy may contest the listed maximum allowable cost for a
71	71	42particular drug or medical product or device.
72	72	43 (g) A pharmacy may base its appeal on one or more of the following:
73	73	44 (1) The maximum allowable cost established for a particular drug or medical product or
74	74	45device is below the cost at which the drug or medical product or device is generally available for
75	75	46purchase by Massachusetts licensed wholesalers currently operating in the state; or
76	76	47 (2) The pharmacy benefits manager or covered entity has placed a drug on the list
77	77	48without properly determining that the requirements of subsection (a).
78	78	49 (h) The pharmacy must file its appeal within seven business days of its submission of the
79	79	50initial claim for reimbursement for the drug or medical product or device. The pharmacy benefits
80	80	51manager or covered entity must make a final determination resolving the pharmacy's appeal 4 of 6
81	81	52within seven business days of the pharmacy benefits manager or covered entity's receipt of the
82	82	53appeal.
83	83	54 (i) If the final determination is a denial of the pharmacy's appeal, the pharmacy benefits
84	84	55manager or covered entity must state the reason for the denial and provide the national drug code
85	85	56of an equivalent drug that is generally available for purchase by pharmacies in this state from
86	86	57national or regional wholesalers licensed by the state at a price which is equal to or less than the
87	87	58maximum allowable cost for that drug.
88	88	59 (j) If a pharmacy's appeal is determined to be valid by the pharmacy benefits manager or
89	89	60covered entity, the pharmacy benefits manager or covered entity shall adjust the maximum
90	90	61allowable cost of the drug or medical product or device for the appealing pharmacy. The
91	91	62adjustment for the appealing pharmacy shall be effective from the date the pharmacy's appeal
92	92	63was filed, and the pharmacy benefits manager or covered entity shall provide reimbursement to
93	93	64the appealing pharmacy and may require the appealing pharmacy to reverse and rebill the claim
94	94	65in question in order to receive the corrected reimbursement.
95	95	66 (k) Once a pharmacy's appeal is determined to be valid by the pharmacy benefits manager
96	96	67or covered entity, the pharmacy benefits manager or covered entity shall adjust the maximum
97	97	68allowable cost of the drug or medical product or device to which the maximum allowable cost
98	98	69applies for all similar pharmacies in the network as determined by the pharmacy benefits
99	99	70manager within 3 business days.
100	100	71 (l) A pharmacy benefits manager or covered entity shall make available on its secure web
101	101	72site information about the appeals process, including, but not limited to, a telephone number or
102	102	73process that a pharmacy may use to submit maximum allowable cost appeals. The medical 5 of 6
103	103	74products and devices subject to the requirements of this part are limited to the medical products
104	104	75and devices included as a pharmacy benefit under the pharmacy benefits contract.
105	105	76 (m) A pharmacy shall not disclose to any third party the maximum allowable cost lists
106	106	77and any related information it receives from a pharmacy benefits manager or covered entity;
107	107	78provided, a pharmacy may share such lists and related information with a pharmacy services
108	108	79administrative organization or similar entity with which the pharmacy has a contract to provide
109	109	80administrative services for that pharmacy. If a pharmacy shares this information with a pharmacy
110	110	81services administrative organization or similar entity, that organization or entity shall not
111	111	82disclose the information to any third party.
112	112	83 (n) The Insurance Commissioner shall enforce this Act and may promulgate regulations
113	113	84to enforce the provisions of this act. The commissioner may examine or audit the books and
114	114	85records of a pharmacy benefits manager providing claims processing services or other
115	115	86prescription drug or device services for a health benefit plan to determine if the pharmacy
116	116	87benefits manager is in compliance with this Act. The information or data acquired during an
117	117	88examination is:
118	118	89 (i) Considered proprietary and confidential; and
119	119	90 (ii) Not subject to the Freedom of Information Act of Massachusetts
120	120	91 (o) In any participation contracts between pharmacy benefits managers and pharmacists
121	121	92or pharmacies providing prescription drug coverage for health benefit plans, no pharmacy or
122	122	93pharmacist may be prohibited, restricted, or penalized in any way from disclosing to any covered
123	123	94person any healthcare information that the pharmacy or pharmacist deems appropriate regarding
124	124	95the nature of treatment, risks, or alternatives thereto, the availability of alternate therapies, 6 of 6
125	125	96consultations, or tests, the decision of utilization reviewers or similar persons to authorize or
126	126	97deny services, the process that is used to authorize or deny healthcare services or benefits, or
127	127	98information on financial incentives and structures used by the insurer.
128	128	99 (p) Further any such contract as stated above shall not prohibit a pharmacist or pharmacy
129	129	100from providing an insured individual information on the amount of the insured's cost share for
130	130	101such insured's prescription drug and the clinical efficacy of a more affordable alternative drug if
131	131	102one is available. Neither a pharmacy nor a pharmacist shall be penalized by a pharmacy benefits
132	132	103manager for disclosing such information to an insured or for selling to an insured a more
133	133	104affordable alternative if one is available.