Massachusetts 2025-2026 Regular Session

Massachusetts House Bill H1326 Compare Versions

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

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2	2	HOUSE DOCKET, NO. 2359 FILED ON: 1/16/2025
3	3	HOUSE . . . . . . . . . . . . . . . No. 1326
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 prescription medications.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :DATE ADDED:Alan Silvia7th Bristol1/16/2025 1 of 7
16	16	HOUSE DOCKET, NO. 2359 FILED ON: 1/16/2025
17	17	HOUSE . . . . . . . . . . . . . . . No. 1326
18	18	By Representative Silvia of Fall River, a petition (accompanied by bill, House, No. 1326) of
19	19	Alan Silvia for legislation to ensure access to prescription medications. Financial Services.
20	20	[SIMILAR MATTER FILED IN PREVIOUS SESSION
21	21	SEE HOUSE, NO. 3587 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 prescription medications.
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 inclusive of all discounts when the claim is processed or taken
37	37	8retroactively
38	38	9 (b) Before a pharmacy benefits manager or covered entity may place a drug on a
39	39	10maximum allowable cost list the drug must be listed as "A" or "AB" rated in the most recent 2 of 7
40	40	11version of the FDA's Approved Drug Products with Therapeutic Equivalence Evaluations, also
41	41	12known as the Orange Book, or has an "NR" or "NA" rating or a similar rating by a nationally
42	42	13recognized reference; and that there are at least two therapeutically equivalent, multiple source
43	43	14drugs, or at least one generic drug available from one manufacturer, available for purchase by
44	44	15network pharmacies from national or regional wholesalers.
45	45	16 (c) If a drug that has been placed on a maximum allowable cost list no longer meets the
46	46	17requirements of subsection (a), the drug shall be removed from the maximum allowable cost list
47	47	18by the pharmacy benefits manager or covered entity within 3 business days after the drug no
48	48	19longer meets the requirements of subsection (a).
49	49	20 (d) A pharmacy benefits manager or covered entity shall make available to each
50	50	21pharmacy with which the pharmacy benefits manager or covered entity has a contract and to
51	51	22each pharmacy included in a network of pharmacies served by a pharmacy services
52	52	23administrative organization
53	53	24 with which the pharmacy benefits manager or covered entity has a contract, at the
54	54	25beginning of the term of a contract upon renewal of a contract, or upon request:
55	55	26 (1) The sources used to determine the maximum allowable costs for the drugs and
56	56	27medical products and devices on each maximum allowable cost list;
57	57	28 (2) Every maximum allowable cost for individual drugs used by that pharmacy benefits
58	58	29manager or covered entity for patients served by that contracted pharmacy; and
59	59	30 (3) Upon request, every maximum allowable cost list used by that pharmacy benefits
60	60	31manager or covered entity for patients served by that contracted pharmacy. 3 of 7
61	61	32 (e) A pharmacy benefits manager or covered entity shall:
62	62	33 (1) Ensure the maxim allowable cost (if used) or the ingredient cost (if not used) is equal
63	63	34to or greater than the pharmacies acquisition cost for all covered medications. A maximum
64	64	35allowable cost equal to or greater than the National Average Drug Acquisition Cost shall be
65	65	36deemed in compliance with the requirement to ensure it is greater than or equal to the pharmacies
66	66	37acquisition cost. (2) Ensure the maximum allowable cost for non-affiliated pharmacies is equal to
67	67	38or greater than the maximum allowable cost to pharmacies affiliated with or owned by the
68	68	39pharmacy benefit manager.
69	69	40 (3) The pharmacy benefit manager shall update each maximum allowable cost list at least
70	70	41every 3 business days (4) Make the updated lists available to every pharmacy with which the
71	71	42pharmacy benefits manager or covered entity has a contract and to every pharmacy included in a
72	72	43network of pharmacies served by a pharmacy services administrative organization with which
73	73	44the pharmacy benefits manager or covered entity has a contract, in a readily accessible, secure
74	74	45and usable web-based format or other comparable format or process; and
75	75	46 (5) Utilize the updated maximum allowable costs to calculate the payments made to the
76	76	47contracted pharmacies within 2 business days.
77	77	48 (f) A pharmacy benefits manager or covered entity shall establish a clearly defined
78	78	49process through which a pharmacy may contest the cost for a particular drug or medical product
79	79	50or device.
80	80	51 (g) A pharmacy may base its appeal on one or more of the following: 4 of 7
81	81	52 (1) The ingredient cost established for a particular drug or medical product or device is
82	82	53below the cost at which the drug or medical product or device is generally available for purchase
83	83	54by Massachusetts licensed wholesalers currently operating in the state; or
84	84	55 (2) The pharmacy benefits manager or covered entity has placed a drug on the maximum
85	85	56allowable cost list without properly determining that the requirements of subsection (a).
86	86	57 (h) The pharmacy must file its appeal within seven business days of its submission of the
87	87	58initial claim for reimbursement for the drug or medical product or device. A Pharmacy Services
88	88	59Administrative Organization (PSAO) may appeal on behalf of a pharmacy or group of
89	89	60pharmacies. The pharmacy benefits manager or covered entity must make a final determination
90	90	61resolving the pharmacy's appeal within seven business days of the pharmacy benefits manager or
91	91	62covered entity's receipt of the appeal.
92	92	63 (i) If the final determination is a denial of the pharmacy's appeal, the pharmacy benefits
93	93	64manager or covered entity must state the reason for the denial and provide the national drug code
94	94	65of an equivalent drug that is generally available for purchase by pharmacies in this state from
95	95	66national or regional wholesalers licensed by the state at a price which is equal to or less than the
96	96	67cost for that drug.
97	97	68 (j) If a pharmacy's appeal is determined to be valid by the pharmacy benefits manager or
98	98	69covered entity, the pharmacy benefits manager or covered entity shall retroactively adjust the
99	99	70cost of the drug or medical product or device and reprocess all claims that were paid incorrectly.
100	100	71The adjustment shall be effective from the date the pharmacy's appeal was filed, and the
101	101	72pharmacy benefits manager or covered entity shall provide reimbursement for all reprocessed
102	102	73claims. 5 of 7
103	103	74 (k) Once a pharmacy's appeal is determined to be valid by the pharmacy benefits manager
104	104	75or covered entity, the pharmacy benefits manager or covered entity shall adjust the cost of the
105	105	76drug
106	106	77 or medical product or device for all similar pharmacies in the network as determined by
107	107	78the pharmacy benefits manager within 3 business days.
108	108	79 (l) A pharmacy benefits manager or covered entity shall make available on its secure web
109	109	80site information about the appeals process, including, but not limited to, a telephone number or
110	110	81process that a pharmacy may use to submit cost appeals. The medical products and devices
111	111	82subject to the requirements of this part are limited to the medical products and devices included
112	112	83as a pharmacy benefit under the pharmacy benefits contract.
113	113	84 (m) A pharmacy shall not disclose to any third party the cost lists and any related
114	114	85information it receives from a pharmacy benefits manager or covered entity; provided, a
115	115	86pharmacy may share such lists and related information with a pharmacy services administrative
116	116	87organization or similar entity with which the pharmacy has a contract to provide administrative
117	117	88services for that pharmacy. If a pharmacy shares this information with a pharmacy services
118	118	89administrative organization or similar entity, that organization or entity shall not disclose the
119	119	90information to any third party.
120	120	91 (n) A pharmacy benefits manager or covered entity is prohibited from applying
121	121	92retroactive discounts including but not limited to Generic Effective Rate and Brand Effective
122	122	93Rate. All discounts must be applied when the claim is paid.
123	123	94 (o) A pharmacy benefits manager or covered entity shall include payment for covered
124	124	95medications in its explanation of benefits 6 of 7
125	125	96 SECTION 2. Chapter 118E Section 9B is hereby amended by adding:-
126	126	97 All MassHealth Managed Care Organizations and Accountable Care Organizations are
127	127	98required to reimburse pharmacies at the same rate as described in the MassHealth Pharmacy
128	128	99Provider Manual.
129	129	100 The Insurance Commissioner shall enforce this Act and shall promulgate regulations to
130	130	101enforce the provisions of this act. The commissioner may examine or audit the books and records
131	131	102of a pharmacy benefits manager providing claims processing services or other prescription drug
132	132	103or device services for a health benefit plan to determine if the pharmacy benefits manager is in
133	133	104compliance with this Act. The information or data acquired during an examination is:
134	134	105 (i) Considered proprietary and confidential; and
135	135	106 (ii) Not subject to the Freedom of Information Act of Massachusetts
136	136	107 (o) In any participation contracts between pharmacy benefits managers and pharmacists
137	137	108or pharmacies providing prescription drug coverage for health benefit plans, no pharmacy or
138	138	109pharmacist may be prohibited, restricted, or penalized in any way from disclosing to any covered
139	139	110person any healthcare information that the pharmacy or pharmacist deems appropriate regarding
140	140	111the nature of treatment, risks, or alternatives thereto, the availability of alternate therapies,
141	141	112consultations, or tests, the decision of utilization reviewers or similar persons to authorize or
142	142	113deny services, the process that is used to authorize or deny healthcare services or benefits, or
143	143	114information on financial incentives and structures used by the insurer.
144	144	115 (p) Further any such contract as stated above shall not prohibit a pharmacist or pharmacy
145	145	116from providing an insured individual information on the amount of the insured's cost share for 7 of 7
146	146	117such insured's prescription drug and the clinical efficacy of a more affordable alternative drug if
147	147	118one is available. Neither a pharmacy nor a pharmacist shall be penalized by a pharmacy benefits
148	148	119manager for disclosing such information to an insured or for selling to an insured a more
149	149	120affordable alternative if one is available.