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HOUSE DOCKET, NO. 2059 FILED ON: 1/15/2025
HOUSE . . . . . . . . . . . . . . . No. 1337
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
Andres X. Vargas and Kate Donaghue
_________________
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 relative to opioid use disorder treatment and rehabilitation coverage.
_______________
PETITION OF:
NAME:DISTRICT/ADDRESS :DATE ADDED:Andres X. Vargas3rd Essex1/15/2025Kate Donaghue19th Worcester1/15/2025 1 of 9
HOUSE DOCKET, NO. 2059 FILED ON: 1/15/2025
HOUSE . . . . . . . . . . . . . . . No. 1337
By Representatives Vargas of Haverhill and Donaghue of Westborough, a petition (accompanied
by bill, House, No. 1337) of Andres X. Vargas and Kate Donaghue relative to opioid use
disorder treatment and rehabilitation. Financial Services.
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Fourth General Court
(2025-2026)
_______________
An Act relative to opioid use disorder treatment and rehabilitation coverage.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Chapter 32A of the General Laws, as amended by chapter xx of the acts of
22024, is hereby amended by inserting after section 17Y the following new section:-
3 Section 17Z. (a) Coverage offered by the commission to an active or retired employee of
4the commonwealth insured under the group insurance commission shall provide coverage for
5prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists, used in
6the treatment of opioid use disorder; provided, however that the coverage for such prescribed,
7administered, ordered or dispensed opioid antagonists and opioid agonists, including partial
8agonists, shall be deemed medically necessary and shall not require prior authorization; and
9provided further that a prescription from a health care practitioner shall not be required for
10coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid
11antagonist and an opioid agonist, including partial agonists, shall not be subject to any
12deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost- 2 of 9
13sharing shall be required if the applicable plan is governed by the Internal Revenue Code and
14would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
15 (b) The commission shall provide coverage for an opioid antagonist and an opioid
16agonist, including partial agonists, used in the treatment of opioid use disorder as a medical
17benefit when dispensed or administered by the health care facility, including substance use
18treatment facility, in which the opioid antagonist or opioid agonist, including partial agonists,
19used in the treatment of opioid use disorder was prescribed, administered, or ordered and shall
20provide coverage as a pharmacy benefit for an opioid antagonist and an opioid agonist, including
21partial agonists, used in the treatment of opioid use disorder dispensed by a pharmacist;
22provided, however, that the rate to be reimbursed under the medical benefit shall not exceed the
23commission’s average in-network pharmacy benefit rate and the health care facility shall not
24balance bill the patient. If dispensed directly to or administered to the patient, the commission
25shall ensure cost to the health care facility is covered through reimbursement or other mechanism
26as determined by the commission in consultation with the Department of Public Health, the
27Division of Insurance, and the Division of Medical Assistance.
28 SECTION 2. Chapter 118E of the General Laws, as amended by chapter xx of the Acts of
292024, is hereby amended by inserting after section 10Y the following new section:-
30 Section 10Z. (a) The division and its contracted health insurers, health plans, health
31maintenance organizations, behavioral health management firms and third-party administrators
32under contract to a Medicaid managed care organization, accountable care organization or
33primary care clinician plan shall provide coverage for prescribed or dispensed opioid antagonists
34and opioid agonists, including partial agonists, used in the treatment of opioid use disorder; 3 of 9
35provided, however that the coverage for such prescribed, administered, ordered or dispensed
36opioid antagonists and opioid agonists, including partial agonists, shall be deemed medically
37necessary and shall not require prior authorization; and provided further that a prescription from
38a health care practitioner shall not be required for coverage of opioid antagonists and opioid
39agonists, including partial agonists. An opioid antagonist and an opioid agonist, including partial
40agonists, shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits;
41provided, however, that cost-sharing shall be required if the applicable plan is governed by the
42Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-
43sharing for this service.
44 (b) The division and its contracted health insurers, health plans, health maintenance
45organizations, behavioral health management firms and third-party administrators under contract
46to a Medicaid managed care organization, accountable care organization or primary care
47clinician plan shall provide coverage for an opioid antagonist and an opioid agonist, including
48partial agonists, used in the treatment of opioid use disorder as a medical benefit when dispensed
49or administered by the health care facility, including substance use treatment facility, in which
50the opioid antagonist or opioid agonist, including partial agonists, used in the treatment of opioid
51use disorder was prescribed, administered, or ordered and shall provide coverage as a pharmacy
52benefit for an opioid antagonist and an opioid agonist, including partial agonists, used in the
53treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the rate to
54be reimbursed under the medical benefit shall not exceed the carrier’s average in-network
55pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed
56directly to or administered to the patient, the division shall ensure cost to the health care facility 4 of 9
57is covered through reimbursement or other mechanism as determined by the commission in
58consultation with the Department of Public Health and the Division of Insurance.
59 SECTION 3. Chapter 175 of the General Laws, as amended by chapter xx of the Act of
602024 is hereby amended by inserting after section 47BBB the following new section:-
61 Section 47CCC. (a) Any policy, contract, agreement, plan or certificate of insurance
62issued, delivered or renewed within the commonwealth, which is considered creditable coverage
63under section 1 of chapter 111M, shall provide coverage for prescribed or dispensed opioid
64antagonists and opioid agonists, including partial agonists, used in the treatment of opioid use
65disorder; provided, however that the coverage for such prescribed, administered, ordered or
66dispensed opioid antagonists and opioid agonists, including partial agonists, shall be deemed
67medically necessary and shall not require prior authorization; and provided further that a
68prescription from a health care practitioner shall not be required for coverage of opioid
69antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid
70agonist, including partial agonists, shall not be subject to any deductible, coinsurance,
71copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the
72applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status
73as a result of the prohibition on cost-sharing for this service.
74 (b) The policy, contract, agreement, plan or certificate of insurance shall provide
75coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the
76treatment of opioid use disorder as a medical benefit when dispensed or administered by the
77health care facility, including substance use treatment facility, in which the opioid antagonist or
78opioid agonist, including partial agonists, used in the treatment of opioid use disorder was 5 of 9
79prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an
80opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of
81opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed
82under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate
83and the health care facility shall not balance bill the patient. If dispensed directly to or
84administered to the patient, the division shall ensure cost to the health care facility is covered
85through reimbursement or other mechanism as determined by the division in consultation with
86the Department of Public Health and the Division of Medical Assistance.
87 SECTION 4. Chapter 176A of the General Laws, as amended by chapter xx of the Act of
882024 is hereby amended by inserting after section 8CCC the following new section:-
89 Section 8DDD. (a) Any contract between a subscriber and the corporation under an
90 individual or group hospital service plan that is delivered, issued or renewed within the
91 commonwealth shall provide coverage for prescribed or dispensed opioid antagonists and
92opioid agonists, including partial agonists, used in the treatment of opioid use disorder; provided,
93however that the coverage for such prescribed, administered, ordered or dispensed opioid
94antagonists and opioid agonists, including partial agonists, shall be deemed medically necessary
95and shall not require prior authorization; and provided further that a prescription from a health
96care practitioner shall not be required for coverage of opioid antagonists and opioid agonists,
97including partial agonists. An opioid antagonist and an opioid agonist, including partial agonists,
98shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits;
99provided, however, that cost-sharing shall be required if the applicable plan is governed by the 6 of 9
100Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-
101sharing for this service.
102 (b) Such contracts shall provide coverage for an opioid antagonist and an opioid agonist,
103including partial agonists, used in the treatment of opioid use disorder as a medical benefit when
104dispensed or administered by the health care facility, including substance use treatment facility,
105in which the opioid antagonist or opioid agonist, including partial agonists, used in the treatment
106of opioid use disorder was prescribed, administered, or ordered and shall provide coverage as a
107pharmacy benefit for an opioid antagonist and an opioid agonist, including partial agonists, used
108in the treatment of opioid use disorder dispensed by a pharmacist; provided, however, that the
109rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network
110pharmacy benefit rate and the health care facility shall not balance bill the patient. If dispensed
111directly to or administered to the patient, the division shall ensure cost to the health care facility
112is covered through reimbursement or other mechanism as determined by the division in
113consultation with the Department of Public Health and the Division of Medical Assistance.
114 SECTION 5. Chapter 176B of the General Laws, as amended by chapter xx of the Act of
1152024 is hereby amended by inserting after section 4CCC the following new section:-
116 Section 4DDD. (a) A subscription certificate under an individual or group medical
117service
118 agreement delivered, issued or renewed within the commonwealth shall provide coverage
119for prescribed or dispensed opioid antagonists and opioid agonists, including partial agonists,
120used in the treatment of opioid use disorder; provided, however that the coverage for such
121prescribed, administered, ordered or dispensed opioid antagonists and opioid agonists, including 7 of 9
122partial agonists, shall be deemed medically necessary and shall not require prior authorization;
123and provided further that a prescription from a health care practitioner shall not be required for
124coverage of opioid antagonists and opioid agonists, including partial agonists. An opioid
125antagonist and an opioid agonist, including partial agonists, shall not be subject to any
126deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-
127sharing shall be required if the applicable plan is governed by the Internal Revenue Code and
128would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.
129 (b) The policy, contract, agreement, plan or certificate of insurance shall provide
130coverage for an opioid antagonist and an opioid agonist, including partial agonists, used in the
131treatment of opioid use disorder as a medical benefit when dispensed or administered by the
132health care facility, including substance use treatment facility, in which the opioid antagonist or
133opioid agonist, including partial agonists, used in the treatment of opioid use disorder was
134prescribed, administered, or ordered and shall provide coverage as a pharmacy benefit for an
135opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of
136opioid use disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed
137under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate
138and the health care facility shall not balance bill the patient. If dispensed directly to or
139administered to the patient, the division shall ensure cost to the health care facility is covered
140through reimbursement or other mechanism as determined by the division in consultation with
141the Department of Public Health and the Division of Medical Assistance.
142 SECTION 6. Chapter 176G of the General Laws, as amended by chapter xx of the Act of
1432024 is hereby amended by inserting after section 4UU the following new section:- 8 of 9
144 Section 4VV. (a) An individual or group health maintenance contract that is issued or
145 renewed within or without the commonwealth shall provide coverage for prescribed or
146dispensed opioid antagonists and opioid agonists, including partial agonists, used in the treatment
147of opioid use disorder; provided, however that the coverage for such prescribed, administered,
148ordered or dispensed opioid antagonists and opioid agonists, including partial agonists, shall be
149deemed medically necessary and shall not require prior authorization; and provided further that a
150prescription from a health care practitioner shall not be required for coverage of opioid
151antagonists and opioid agonists, including partial agonists. An opioid antagonist and an opioid
152agonist, including partial agonists, shall not be subject to any deductible, coinsurance,
153copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the
154applicable plan is governed by the Internal Revenue Code and would lose its tax-exempt status
155as a result of the prohibition on cost-sharing for this service.
156 (b) The individual or group health maintenance contract shall provide coverage for an
157opioid antagonist and an opioid agonist, including partial agonists, used in the treatment of
158opioid use disorder as a medical benefit when dispensed or administered by the health care
159facility, including substance use treatment facility, in which the opioid antagonist or opioid
160agonist, including partial agonists, used in the treatment of opioid use disorder was prescribed,
161administered, or ordered and shall provide coverage as a pharmacy benefit for an opioid
162antagonist and an opioid agonist, including partial agonists, used in the treatment of opioid use
163disorder dispensed by a pharmacist; provided, however, that the rate to be reimbursed under the
164medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate and the
165health care facility shall not balance bill the patient. If dispensed directly to or administered to
166the patient, the division shall ensure cost to the health care facility is covered through 9 of 9
167reimbursement or other mechanism as determined by the division in consultation with the
168Department of Public Health and the Division of Medical Assistance.