This document is a quarterly report submitted by the Executive Office of Health and Human Services to state committees regarding the Children's Medical Security Plan for the period from October 1, 2024, through December 31, 2024. It provides statistical data on the program's performance, noting that 87,730 children were eligible for coverage at the end of the quarter. The report details financial expenditures totaling approximately $11.7 million, which covered medical, dental, and pharmacy services for about 38,500 active members. Additionally, it outlines policy changes effective January 1, 2025, where premiums were removed for families earning up to 300% of the federal poverty level and all copayments were eliminated for all members.
This bill empowers the Health Policy Commission to investigate whether nonprofit hospitals are setting drug prices that are unreasonable or excessive. Upon receiving a referral, the commission can require hospitals to submit detailed information about their pricing methods, including how they calculate markups and how they treat drugs acquired under the 340B program. While the bill mandates the disclosure of specific pricing data, it includes strong confidentiality protections to prevent hospitals from revealing trade secrets or sensitive financial details. If the commission finds a price is too high, it will issue a public report with findings and recommendations, which may then trigger an independent investigation by the Attorney General. Ultimately, the legislation aims to increase transparency in hospital drug pricing without directly mandating specific price reductions.
This bill caps the out-of-pocket cost for insulin at $100 per 30-day supply for all patients, regardless of insulin type or prescription amount. It requires pharmaceutical companies with Medicaid rebate agreements to offer free 30-day insulin supplies to individuals urgently needing insulin (with less than 7 days' supply) who meet income criteria (≤400% of federal poverty level) and lack private drug coverage. Eligible individuals must provide proof of financial need and have a prescription. The cap applies to all insurers, manufacturers, and government programs covered under the bill, ensuring consistent cost limits without requiring additional coverage.
H 4944 allows pharmacists to dispense insulin in emergency situations without immediate prescription authorization. It defines an "emergency situation" as one where a patient cannot quickly obtain a doctor's approval, and requires pharmacists to use their professional judgment to determine if insulin is essential to prevent harm. The bill limits emergency insulin dispensing to a 30-day supply (or standard unit size if larger) and prohibits repeat dispensing to the same patient more than once every six months. This directly affects patients facing urgent insulin needs and pharmacists who may provide this emergency care under these specific guidelines. The law amends multiple sections of state law to include this emergency access provision.
H 4956 requires health insurance plans to cover clinician-administered drugs (outpatient prescriptions typically given in clinics or hospitals, like IV therapies) without extra costs or restrictions. It prohibits insurers from charging patients higher copays, denying coverage, or forcing them to use specific pharmacies when getting these drugs from their chosen provider or pharmacy. The bill also bans insurers from limiting coverage based on where the drug is dispensed or reducing payments to providers who source drugs from non-network pharmacies. This directly affects patients seeking these treatments, healthcare providers, and health benefit carriers. Insurers may offer but cannot mandate home infusion services or external infusion sites.
This bill requires pharmacy benefit managers (PBMs) in Massachusetts to follow specific rules when setting reimbursement rates for pharmacies. PBMs must ensure drugs on their cost lists are therapeutically equivalent, widely available from wholesalers, and not obsolete. Pharmacies can appeal underpayments through a formal process, with PBMs required to respond within 7 business days and adjust rates if appeals are upheld. The law directly affects pharmacies and PBMs, preventing PBMs from reimbursing pharmacies less than what they pay their own affiliated pharmacies for identical services.
This bill (HD 2353) provides prescription drug cost reimbursements to elderly governmental retirees. It defines "elderly governmental retiree" as any retired employee aged 70 or older who has been retired for at least five years. The bill requires the State Retirees Benefits Trust Fund to reimburse retirees for at least 25% of their prescription drug co-payments, with municipalities offering drug coverage required to participate in the program. This creates a direct financial benefit for eligible retirees through state-funded reimbursement, administered via the Trust Fund.
This bill (HD 1305) requires pharmacy benefit managers (PBMs) operating in Massachusetts to follow specific rules when setting reimbursement rates for pharmacies. It mandates that PBMs provide transparent access to their "maximum allowable cost" drug lists, update them within 7 days if pharmacy acquisition costs rise by 10% or more, and establish a clear 7-business-day appeal process for pharmacies challenging low reimbursements. Pharmacies can refuse services if paid below their actual drug purchase cost ("pharmacy acquisition cost"), and PBMs must reimburse pharmacies equally to what they pay their own affiliated pharmacies for the same services. The law applies to all PBMs, including those working with MassHealth, and violations are classified as deceptive trade practices under existing law.
This bill requires pharmacy benefits managers (PBMs) to obtain a license from the Massachusetts insurance commissioner before providing drug pricing services. It establishes rules for how PBMs set reimbursement rates for prescription drugs ("Maximum Allowable Cost" or MAC), requiring them to update these rates every 7 days and base them on FDA-approved drug lists. PBMs must also provide transparent pricing information to hospitals and insurers about the difference between what they pay pharmacies and what they bill covered entities. Pharmacies can appeal low reimbursement rates under a standardized process, and PBMs must respond to appeals within 10 business days. The law directly affects PBMs, hospitals, insurers, and employers offering health coverage in Massachusetts.
HD 2276 establishes new duties for pharmacy benefit managers (PBMs) to act transparently and in the best interest of patients, health insurance plans, and pharmacies. It requires PBMs to disclose conflicts of interest, explain fees clearly, and prevent "spread pricing" (charging more than the drug cost plus dispensing fee). The law prioritizes patient interests over other parties and mandates transparency in formulary design, billing, and pricing. This directly affects all PBMs working with health insurance plans in the state, including their fees, pricing practices, and interactions with patients and pharmacies.
