Healthcare (Prescription Drugs)

This bill prevents health insurers from forcing patients to switch prescription drugs without medical necessity ("nonmedical switching"). It requires insurers to maintain coverage for drugs a patient is medically stable on (as determined by their doctor), unless the drug is removed due to FDA safety concerns or manufacturing issues. Insurers must provide a clear, fast-track process for patients to request coverage exemptions, responding within 72 hours (24 hours for emergencies), with automatic approval if they miss deadlines. The bill directly affects patients on stable prescription regimens and health insurers managing drug coverage under health benefit plans.

This bill requires health insurance plans in Massachusetts covering prescription drugs to establish a separate out-of-pocket limit for those drugs - including specialty drugs - distinct from other medical costs. The limit cannot exceed the federal minimum annual deductible for high-deductible health plans (set under IRS code 26 U.S.C. §223), which covers both self-only and family coverage. It defines "out-of-pocket limit" to include cost-sharing expenses like copays under the Affordable Care Act. The rule applies to all relevant health insurance policies renewed or issued on or after January 1, 2026, directly affecting insurers and patients with prescription drug coverage.

This bill requires pharmacy benefit managers (insurance companies that manage drug benefits) to pay community pharmacies fairly for services, matching or exceeding Massachusetts Medicaid rates for both drug costs and dispensing fees. It prohibits "pharmacy steering" (directing prescriptions to pharmacies owned by the benefit manager) and mandates that all pharmacies, including community ones, can provide specialty medications if they meet standard service requirements. The bill also requires transparency in how drug costs are calculated and gives pharmacies a 7-day process to appeal underpayment claims. It directly affects community pharmacies, benefit managers, and patients seeking medication access, aiming to ensure equitable treatment for independent pharmacies.

This bill prohibits pharmacy benefit managers (PBMs) from discriminating against hospitals and clinics participating in the federal 340B drug discount program. It specifically bans PBMs from paying lower rates for 340B drugs than non-340B drugs, charging extra fees for 340B participation, restricting network access based on 340B status, or imposing higher patient costs (like extra copays) when using 340B providers. The law directly affects safety-net hospitals, clinics, and their patients who rely on the 340B program to access discounted medications. It ensures these providers aren’t penalized for participating in the federal program through PBM billing practices.

This bill caps out-of-pocket insulin costs at $100 per 30-day supply for all patients, regardless of insulin type or quantity needed. It directly affects insulin users, drug manufacturers, and insurers by requiring them to limit patient costs. Drug companies must offer free 30-day insulin supplies to eligible individuals urgently needing insulin (with less than a 7-day supply) who meet income limits (≤400% federal poverty level) and lack private drug coverage. The law also mandates manufacturers to establish accessible application processes for this assistance program within 14 days.