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SENATE DOCKET, NO. 1312 FILED ON: 1/16/2025
SENATE . . . . . . . . . . . . . . No. 694
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
Brendan P. Crighton
_________________
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 empowering health care consumers.
_______________
PETITION OF:
NAME:DISTRICT/ADDRESS :Brendan P. CrightonThird EssexJames B. EldridgeMiddlesex and Worcester2/28/2025Bruce E. TarrFirst Essex and Middlesex2/28/2025 1 of 13
SENATE DOCKET, NO. 1312 FILED ON: 1/16/2025
SENATE . . . . . . . . . . . . . . No. 694
By Mr. Crighton, a petition (accompanied by bill, Senate, No. 694) of Brendan P. Crighton,
James B. Eldridge and Bruce E. Tarr for legislation to empower health care consumers.
Financial Services.
[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE SENATE, NO. 605 OF 2023-2024.]
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Fourth General Court
(2025-2026)
_______________
An Act empowering health care consumers.
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 175 of the General Laws is hereby amended by inserting after
2section 47II the following section:-
3 Section 47JJ.
4 (a) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or
5renewed within the Commonwealth on or after January 1, 2018, shall:
6 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
7whether the plan uses a formulary. The notice shall include an explanation of what a formulary
8is, how the plan determines which prescription drugs are included or excluded, and how often the
9plan reviews the contents of the formulary. 2 of 13
10 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
11internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
12and providers.
13 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
14formularies within 72 hours after making the change.
15 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
16or formularies for each product offered by the plan.
17 (5) Include all of the following on any published formulary for any product offered by the
18plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
19 (i) Any prior authorization, step therapy requirements, or utilization management
20requirements for each specific drug included on the formulary.
21 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
22the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
23in the evidence of coverage.
24 (iii) For prescription drugs covered under the plans medical benefit and typically
25administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
26drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
27consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
28is staffed at least during normal business hours.
29 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
30subject to a coinsurance and dispensed at an in-network pharmacy the plan must: 3 of 13
31 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
32 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
33each specific drug included on the formulary, as follows:
34 Under $100 – $.
35 $100-$250 – $$.
36 $251-$500 – $$$.
37 $500-$1,000 – $$$$.
38 Over $1,000 -- $$$$$
39 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
40list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
41through a mail order facility utilizing the same ranges as provided in subclause (B).
42 (vi) A description of how medications will specifically be included in or excluded from
43the deductible, including a description of out-of-pocket costs that may not apply to the deductible
44for a medication.
45 (b) The Division of Insurance shall develop a standard formulary template which a health
46care service plan shall use to comply with paragraph (4).
47 SECTION 2. Chapter 176A of the General Laws is hereby amended by inserting after
48section 8KK the following section:-
49 Section 8LL. 4 of 13
50 (a) Any contract between a subscriber and the corporation under an individual or group
51hospital service plan delivered or issued or renewed within the commonwealth on or after
52January 1, 2018, shall:
53 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
54whether the plan uses a formulary. The notice shall include an explanation of what a formulary
55is, how the plan determines which prescription drugs are included or excluded, and how often the
56plan reviews the contents of the formulary.
57 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
58internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
59and providers.
60 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
61formularies within 72 hours after making the change.
62 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
63or formularies for each product offered by the plan.
64 (5) Include all of the following on any published formulary for any product offered by the
65plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
66 (i) Any prior authorization, step therapy requirements, or utilization management
67requirements for each specific drug included on the formulary.
68 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
69the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
70in the evidence of coverage. 5 of 13
71 (iii) For prescription drugs covered under the plans medical benefit and typically
72administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
73drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
74consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
75is staffed at least during normal business hours.
76 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
77subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
78 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
79 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
80each specific drug included on the formulary, as follows:
81 Under $100 – $.
82 $100-$250 – $$.
83 $251-$500 – $$$.
84 $500-$1,000 – $$$$.
85 Over $1,000 -- $$$$$
86 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
87list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
88through a mail order facility utilizing the same ranges as provided in subclause (B). 6 of 13
89 (vi) A description of how medications will specifically be included in or excluded from
90the deductible, including a description of out-of-pocket costs that may not apply to the deductible
91for a medication.
92 (b) The Division of Insurance shall develop a standard formulary template which a health
93care service plan shall use to comply with paragraph (4).
94 SECTION 3. Chapter 176B of the General Laws is hereby amended by inserting after
95section 4KK the following section:-
96 Section 4LL.
97 (a) Any subscription certificate under an individual or group medical service agreement
98delivered, issued or renewed within the commonwealth on or after January 1, 2018, shall:
99 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
100whether the plan uses a formulary. The notice shall include an explanation of what a formulary
101is, how the plan determines which prescription drugs are included or excluded, and how often the
102plan reviews the contents of the formulary.
103 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
104internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
105and providers.
106 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
107formularies within 72 hours after making the change.
108 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
109or formularies for each product offered by the plan. 7 of 13
110 (5) Include all of the following on any published formulary for any product offered by the
111plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
112 (i) Any prior authorization, step therapy requirements, or utilization management
113requirements for each specific drug included on the formulary.
114 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
115the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
116in the evidence of coverage.
117 (iii) For prescription drugs covered under the plans medical benefit and typically
118administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
119drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
120consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
121is staffed at least during normal business hours.
122 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
123subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
124 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
125 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
126each specific drug included on the formulary, as follows:
127 Under $100 – $.
128 $100-$250 – $$.
129 $251-$500 – $$$. 8 of 13
130 $500-$1,000 – $$$$.
131 Over $1,000 -- $$$$$
132 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
133list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
134through a mail order facility utilizing the same ranges as provided in subclause (B).
135 (vi) A description of how medications will specifically be included in or excluded from
136the deductible, including a description of out-of-pocket costs that may not apply to the deductible
137for a medication.
138 (b) The Division of Insurance shall develop a standard formulary template which a health
139care service plan shall use to comply with paragraph (4).
140 SECTION 4. Chapter 176G of the General Laws is hereby amended by inserting after
141section 4CC the following section:-
142 Section 4DD.
143 (a) Any individual or group health maintenance contract issued on or after January 1,
1442018, shall:
145 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
146whether the plan uses a formulary. The notice shall include an explanation of what a formulary
147is, how the plan determines which prescription drugs are included or excluded, and how often the
148plan reviews the contents of the formulary. 9 of 13
149 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
150internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
151and providers.
152 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
153formularies within 72 hours after making the change.
154 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
155or formularies for each product offered by the plan.
156 (5) Include all of the following on any published formulary for any product offered by the
157plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
158 (i) Any prior authorization, step therapy requirements, or utilization management
159requirements for each specific drug included on the formulary.
160 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
161the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
162in the evidence of coverage.
163 (iii) For prescription drugs covered under the plans medical benefit and typically
164administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
165drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
166consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
167is staffed at least during normal business hours.
168 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
169subject to a coinsurance and dispensed at an in-network pharmacy the plan must: 10 of 13
170 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
171 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
172each specific drug included on the formulary, as follows:
173 Under $100 – $.
174 $100-$250 – $$.
175 $251-$500 – $$$.
176 $500-$1,000 – $$$$.
177 Over $1,000 -- $$$$$
178 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
179list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
180through a mail order facility utilizing the same ranges as provided in subclause (B).
181 (vi) A description of how medications will specifically be included in or excluded from
182the deductible, including a description of out-of-pocket costs that may not apply to the deductible
183for a medication.
184 (b) The Division of Insurance shall develop a standard formulary template which a health
185care service plan shall use to comply with paragraph (4).
186 SECTION 5. Chapter 32A of the General Laws is hereby amended by inserting after
187section 27 the following section:-
188 Section 28. 11 of 13
189 (a) Any coverage offered by the commission to any active or retired employee of the
190commonwealth who is insured under the group insurance commission on or after January 1,
1912018, shall:
192 (1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding
193whether the plan uses a formulary. The notice shall include an explanation of what a formulary
194is, how the plan determines which prescription drugs are included or excluded, and how often the
195plan reviews the contents of the formulary.
196 (2) Post the formulary or formularies for each product offered by the plan on the plan’s
197internet web site in a manner that is accessible and searchable by potential enrollees, enrollees,
198and providers.
199 (3) Update the formularies posted pursuant to paragraph (2) with any change to those
200formularies within 72 hours after making the change.
201 (4) Use a standard template developed pursuant to subsection (b) to display the formulary
202or formularies for each product offered by the plan.
203 (5) Include all of the following on any published formulary for any product offered by the
204plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):
205 (i) Any prior authorization, step therapy requirements, or utilization management
206requirements for each specific drug included on the formulary.
207 (ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on
208the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier
209in the evidence of coverage. 12 of 13
210 (iii) For prescription drugs covered under the plans medical benefit and typically
211administered by a provider, plans must disclose to enrollees and potential enrollees, all covered
212drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the
213consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that
214is staffed at least during normal business hours.
215 (iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is
216subject to a coinsurance and dispensed at an in-network pharmacy the plan must:
217 (A) disclose the dollar amount of the enrollee’s cost-sharing, or
218 (B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of
219each specific drug included on the formulary, as follows:
220 Under $100 – $.
221 $100-$250 – $$.
222 $251-$500 – $$$.
223 $500-$1,000 – $$$$.
224 Over $1,000 -- $$$$$
225 (v) If the carrier allows the option for mail order pharmacy, the carrier separately must
226list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug
227through a mail order facility utilizing the same ranges as provided in subclause (B). 13 of 13
228 (vi) A description of how medications will specifically be included in or excluded from
229the deductible, including a description of out-of-pocket costs that may not apply to the deductible
230for a medication.
231 (b) The Division of Insurance shall develop a standard formulary template which a health
232care service plan shall use to comply with paragraph (4).