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