Massachusetts 2025-2026 Regular Session

Massachusetts House Bill H1330 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. 2283 FILED ON: 1/16/2025
3	3	HOUSE . . . . . . . . . . . . . . . No. 1330
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Alyson M. Sullivan-Almeida
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 relative to pharmacy benefit managers reimbursements to pharmacies in the
13	13	Commonwealth.
14	14	_______________
15	15	PETITION OF:
16	16	NAME:DISTRICT/ADDRESS :DATE ADDED:Alyson M. Sullivan-Almeida7th Plymouth1/16/2025 1 of 5
17	17	HOUSE DOCKET, NO. 2283 FILED ON: 1/16/2025
18	18	HOUSE . . . . . . . . . . . . . . . No. 1330
19	19	By Representative Sullivan-Almeida of Abington, a petition (accompanied by bill, House, No.
20	20	1330) of Alyson M. Sullivan-Almeida relative to pharmacy benefit managers reimbursements to
21	21	pharmacies in the Commonwealth. Financial Services.
22	22	[SIMILAR MATTER FILED IN PREVIOUS SESSION
23	23	SEE HOUSE, NO. 1247 OF 2023-2024.]
24	24	The Commonwealth of Massachusetts
25	25	_______________
26	26	In the One Hundred and Ninety-Fourth General Court
27	27	(2025-2026)
28	28	_______________
29	29	An Act relative to pharmacy benefit managers reimbursements to pharmacies in the
30	30	Commonwealth.
31	31	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
32	32	of the same, as follows:
33	33	1 Chapter 176D of the General Laws, as appearing in the 2022 Official Edition, is hereby
34	34	2amended by inserting after section 3B the following section:-
35	35	3 Section 3C. (a) As used in this section, the following terms shall, unless the context
36	36	4clearly requires otherwise, have the following meanings:
37	37	5
38	38	6 “Maximum allowable cost list” or “list”, a list of drugs used by a pharmacy benefits
39	39	7manager in setting the maximum allowable cost upon which reimbursement to a pharmacy or
40	40	8pharmacist may be based. 2 of 5
41	41	9 "Pharmaceutical wholesaler", a person or entity that sells and distributes prescription
42	42	10pharmaceutical products, including without limitation a full line of brand-name, generic and
43	43	11over-the-counter pharmaceuticals, and that offers regular and private delivery to a pharmacy.
44	44	12 “Pharmacist”, as defined in section 1 of chapter 94C.
45	45	13 “Pharmacist services”, products, goods or services provided as a part of the practice of
46	46	14pharmacy.
47	47	15 “Pharmacy”, as defined in section 1 of chapter 94C.
48	48	16 "Pharmacy acquisition cost", the amount that a pharmaceutical wholesaler charges for a
49	49	17pharmaceutical product as listed on the pharmacy's billing invoice.
50	50	18 “Pharmacy benefits manager”, as defined in section 226 of chapter 175.
51	51	19 "Pharmacy benefits manager affiliate", (i) a pharmacy or pharmacist that directly or
52	52	20indirectly, through 1 or more intermediaries, owns or controls a pharmacy with a pharmacy
53	53	21benefits manager; or (ii) a pharmacy that directly or indirectly, through 1 or more intermediaries,
54	54	22is owned or controlled by or is under common ownership or control with a pharmacy benefits
55	55	23manager.
56	56	24 “Pharmacy benefits plan or program”, a plan or program that pays for, reimburses, covers
57	57	25the cost of or otherwise provides for pharmacist services to individuals who reside in or are
58	58	26employed in the commonwealth.
59	59	27 (b) Before a pharmacy benefits manager places or continues to administer a particular
60	60	28drug on a maximum allowable cost list, the drug shall: (i) be listed as therapeutically equivalent
61	61	29and pharmaceutically equivalent “A” or "B" rated in the United States Food and Drug 3 of 5
62	62	30Administration’s most recent version of the Orange Book or Green Book or have an NR or NA
63	63	31rating by Medi-span, Elsevier Gold Standard Drug Database or a similar rating by a nationally
64	64	32recognized reference; (ii) be available for purchase by each pharmacy in the commonwealth
65	65	33from national or regional wholesalers operating in the commonwealth; and (iii) not be obsolete.
66	66	34 (c) (1) A pharmacy benefits manager shall: (i) provide access to its maximum allowable
67	67	35cost list to each pharmacy subject to the list; (ii) update its maximum allowable cost list on a
68	68	36timely basis, but in no event later than 7 calendar days after an increase of 10 per cent or more in
69	69	37the pharmacy acquisition cost from 60 per cent or more of the pharmaceutical wholesalers doing
70	70	38business in the commonwealth or a change in the methodology upon which the list is based or in
71	71	39the value of a variable involved in the methodology; (iii) provide a process for each pharmacy
72	72	40subject to the maximum allowable cost list to receive prompt notification of an update to the list;
73	73	41and (iv) provide a reasonable administrative appeal procedure to allow pharmacies to challenge
74	74	42maximum allowable costs and reimbursements made under a maximum allowable cost for a
75	75	43specific drug or drugs as not meeting the requirements of this section or being below the
76	76	44pharmacy acquisition cost.
77	77	45 (2) The reasonable administrative appeal procedure shall include a dedicated telephone
78	78	46number and email address or website for the purpose of submitting administrative appeals.
79	79	47Pharmacies shall be able to submit an administrative appeal directly to the pharmacy benefits
80	80	48manager regarding the pharmacy benefits plan or program or through a pharmacy service
81	81	49administrative organization. Pharmacies shall have no less than 7 business days to file an
82	82	50administrative appeal. 4 of 5
83	83	51 (3) The pharmacy benefits manager shall respond to a challenge based on
84	84	52reimbursements made under a maximum allowable cost within 7 business days after receipt of
85	85	53the challenge.
86	86	54 (4) If a challenge is based on maximum allowable cost and the appeal is upheld, the
87	87	55pharmacy benefits manager shall, within 7 business days after receipt of the challenge: (i) make
88	88	56the change in the maximum allowable cost; (ii) permit the challenging pharmacy or pharmacist
89	89	57to reverse and rebill the claim in question; (iii) provide the National Drug Code for the drug that
90	90	58the increase or change is based upon to the pharmacy or pharmacist; and (iv) make the change in
91	91	59the maximum allowable cost effective for each similarly situated pharmacy as defined by the
92	92	60payor subject to the maximum allowable cost list.
93	93	61 (5) If a challenge is based on maximum allowable cost and the appeal is denied, the
94	94	62pharmacy benefits manager shall, within 7 business days after receipt of the challenge, provide
95	95	63the challenging pharmacy or pharmacist the National Drug Code for the drug and the name of the
96	96	64national or regional pharmaceutical wholesalers operating in the commonwealth that have the
97	97	65drug currently in stock at a price below the maximum allowable cost on the list.
98	98	66 (6) If the drug for which the National Drug Code provided by the pharmacy benefits
99	99	67manager is not available at a price below the pharmacy acquisition cost from the pharmaceutical
100	100	68wholesaler from which the pharmacy or pharmacist purchases the majority of prescription drugs
101	101	69for resale, then the pharmacy benefits manager shall adjust the price on the maximum allowable
102	102	70cost list to exceed the challenging pharmacy's pharmacy acquisition cost and permit the
103	103	71pharmacy to reverse and rebill each claim affected by the inability to procure the drug at a cost
104	104	72that is equal to or less than the previously challenged maximum allowable cost. 5 of 5
105	105	73 (d) A pharmacy benefits manager shall not reimburse a pharmacy or pharmacist in an
106	106	74amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits
107	107	75manager affiliate for providing the same pharmacist services. The amount shall be calculated on
108	108	76a per unit basis based on the same generic product identifier or generic code number.
109	109	77 (e) A pharmacy or pharmacist may decline to provide pharmacist services to a patient or
110	110	78pharmacy benefits manager if, as a result of a maximum allowable cost list, a pharmacy or
111	111	79pharmacist would be paid less than the pharmacy acquisition cost of the pharmacy providing
112	112	80pharmacist services.
113	113	81 (f) This section shall apply to the pharmacy benefits manager employed by or under
114	114	82contract with MassHealth or the group insurance commission if, at any time, MassHealth or the
115	115	83group insurance commission engages the services of a pharmacy benefits manager to maintain a
116	116	84maximum allowable cost list.
117	117	85 (g) A violation of this section shall be a deceptive and unfair trade practice as described
118	118	86in section 2 of chapter 93A of the General Laws.