SENATE DOCKET, NO. 1548        FILED ON: 1/16/2015

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 519

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

Barbara A. L'Italien

_________________

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 ensuring transparency of health plan formularies.

_______________

PETITION OF:

SENATE DOCKET, NO. 1548        FILED ON: 1/16/2015

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 519

The Commonwealth of Massachusetts

_______________

In the One Hundred and Eighty-Ninth General Court
(2015-2016)

_______________

An Act relative to ensuring transparency of health plan formularies.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

SECTION 1. Chapter 175 of the General Laws is hereby amended by inserting after section 110M the following section:-

Section 110N. Any policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth on or after January 1, 2017, shall:

(a) Post the formulary for the health plan on the carrier's web site in a manner that is accessible and searchable by enrollees, potential enrollees, and providers;

(b) Update the formulary posted pursuant to subsection (1)(a) of this section no later than twenty-four hours after making a change to the formulary; and

(c) Include on any published formulary for the plan, including but not limited to the formulary posted pursuant to subsection (1)(a) of this section, the following:

(i) Any utilization management edits –- including prior authorization, step therapy edits, quantity limits, or other requirements -- for each specific drug included in the formulary; and

(ii) For each drug included on the formulary and subject to a coinsurance, the range of cost sharing for a potential enrollee if the potential enrollee purchases the drug in person at an in-network pharmacy, as follows: 

(A) Under one hundred dollars: $;

(B) One hundred dollars to two hundred fifty dollars: $$;

(C) Two hundred fifty-one dollars to five hundred dollars: $$$; and

(D) Over five hundred dollars: $$$$. 

(iii) If the carrier allows the option for mail order pharmacy, the carrier separately must list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug through a mail order facility utilizing the same ranges as provided in section (1)(c)(2).

(2) The formulary posted pursuant to subsection (1)(a) of this section must use a template that:

(a) Is standardized across all health plans offered by the carrier;

(b) Uses the United States pharmacopeia classification system;

(c) Organizes drugs by therapeutic class, listing drugs alphabetically; and

(d) Provides a separate list for drugs used to treat a serious illness covered under the plan's medical benefit.

(3) Each carrier offering or renewing a health plan on or after January 1, 2017, must make available to current and potential enrollees the information mandated under section (1) and (2).  The information must be available prior to the beginning of the open enrollment period and must be done via a public website and through a toll free number that is posted on the carrier’s website. 

(4) Each carrier offering or renewing a health plan on or after January 1, 2017, must, no later than thirty days after the offer or renewal date, attest to the office of the insurance commissioner that the carrier has satisfied the requirements of this section.

(5) The Commissioner of the Division of Insurance may adopt rules to implement this section.

(6) For purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under the health plan, including drugs covered under the plan's pharmacy benefit and medical benefit. 

SECTION 2. Chapter 176A of the General Laws is hereby amended by inserting after section 8AA the following section:-

Section 8BB. Any contract between a subscriber and the corporation under an individual or group hospital service plan delivered or issued or renewed within the commonwealth on or after January 1, 2017, shall:

(a) Post the formulary for the health plan on the carrier's web site in a manner that is accessible and searchable by enrollees, potential enrollees, and providers;

(b) Update the formulary posted pursuant to subsection (1)(a) of this section no later than twenty-four hours after making a change to the formulary; and

(c) Include on any published formulary for the plan, including but not limited to the formulary posted pursuant to subsection (1)(a) of this section, the following:

(i) Any utilization management edits –- including prior authorization, step therapy edits, quantity limits, or other requirements -- for each specific drug included in the formulary; and

(ii) For each drug included on the formulary and subject to a coinsurance, the range of cost sharing for a potential enrollee if the potential enrollee purchases the drug in person at an in-network pharmacy, as follows: 

(A) Under one hundred dollars: $;

(B) One hundred dollars to two hundred fifty dollars: $$;

(C) Two hundred fifty-one dollars to five hundred dollars: $$$; and

(D) Over five hundred dollars: $$$$. 

(iii) If the carrier allows the option for mail order pharmacy, the carrier separately must list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug through a mail order facility utilizing the same ranges as provided in section (1)(c)(2).

(2) The formulary posted pursuant to subsection (1)(a) of this section must use a template that:

(a) Is standardized across all health plans offered by the carrier;

(b) Uses the United States pharmacopeia classification system;

(c) Organizes drugs by therapeutic class, listing drugs alphabetically; and

(d) Provides a separate list for drugs used to treat a serious illness covered under the plan's medical benefit.

(3) Each carrier offering or renewing a health plan on or after January 1, 2017, must make available to current and potential enrollees the information mandated under section (1) and (2).  The information must be available prior to the beginning of the open enrollment period and must be done via a public website and through a toll free number that is posted on the carrier’s website. 

(4) Each carrier offering or renewing a health plan on or after January 1, 2017, must, no later than thirty days after the offer or renewal date, attest to the office of the insurance commissioner that the carrier has satisfied the requirements of this section.

(5) The Commissioner of the Division of Insurance may adopt rules to implement this section.

(6) For purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under the health plan, including drugs covered under the plan's pharmacy benefit and medical benefit.

SECTION 3. Chapter 176B of the General Laws is hereby amended by inserting after section 4AA the following section:-

Section 4BB. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth on or after January 1, 2017, shall:

(a) Post the formulary for the health plan on the carrier's web site in a manner that is accessible and searchable by enrollees, potential enrollees, and providers;

(b) Update the formulary posted pursuant to subsection (1)(a) of this section no later than twenty-four hours after making a change to the formulary; and

(c) Include on any published formulary for the plan, including but not limited to the formulary posted pursuant to subsection (1)(a) of this section, the following:

(i) Any utilization management edits –- including prior authorization, step therapy edits, quantity limits, or other requirements -- for each specific drug included in the formulary; and

(ii) For each drug included on the formulary and subject to a coinsurance, the range of cost sharing for a potential enrollee if the potential enrollee purchases the drug in person at an in-network pharmacy, as follows: 

(A) Under one hundred dollars: $;

(B) One hundred dollars to two hundred fifty dollars: $$;

(C) Two hundred fifty-one dollars to five hundred dollars: $$$; and

(D) Over five hundred dollars: $$$$. 

(iii) If the carrier allows the option for mail order pharmacy, the carrier separately must list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug through a mail order facility utilizing the same ranges as provided in section (1)(c)(2).

(2) The formulary posted pursuant to subsection (1)(a) of this section must use a template that:

(a) Is standardized across all health plans offered by the carrier;

(b) Uses the United States pharmacopeia classification system;

(c) Organizes drugs by therapeutic class, listing drugs alphabetically; and

(d) Provides a separate list for drugs used to treat a serious illness covered under the plan's medical benefit.

(3) Each carrier offering or renewing a health plan on or after January 1, 2017, must make available to current and potential enrollees the information mandated under section (1) and (2).  The information must be available prior to the beginning of the open enrollment period and must be done via a public website and through a toll free number that is posted on the carrier’s website. 

(4) Each carrier offering or renewing a health plan on or after January 1, 2017, must, no later than thirty days after the offer or renewal date, attest to the office of the insurance commissioner that the carrier has satisfied the requirements of this section.

(5) The Commissioner of the Division of Insurance may adopt rules to implement this section.

(6) For purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under the health plan, including drugs covered under the plan's pharmacy benefit and medical benefit.

SECTION 4. Chapter 176G of the General Laws is hereby amended by inserting after section 4S the following section:-

Section 4T. Any individual or group health maintenance contract issued on or after January 1, 2017, shall:

(a) Post the formulary for the health plan on the carrier's web site in a manner that is accessible and searchable by enrollees, potential enrollees, and providers;

(b) Update the formulary posted pursuant to subsection (1)(a) of this section no later than twenty-four hours after making a change to the formulary; and

(c) Include on any published formulary for the plan, including but not limited to the formulary posted pursuant to subsection (1)(a) of this section, the following:

(i) Any utilization management edits –- including prior authorization, step therapy edits, quantity limits, or other requirements -- for each specific drug included in the formulary; and

(ii) For each drug included on the formulary and subject to a coinsurance, the range of cost sharing for a potential enrollee if the potential enrollee purchases the drug in person at an in-network pharmacy, as follows: 

(A) Under one hundred dollars: $;

(B) One hundred dollars to two hundred fifty dollars: $$;

(C) Two hundred fifty-one dollars to five hundred dollars: $$$; and

(D) Over five hundred dollars: $$$$. 

(iii) If the carrier allows the option for mail order pharmacy, the carrier separately must list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug through a mail order facility utilizing the same ranges as provided in section (1)(c)(2).

(2) The formulary posted pursuant to subsection (1)(a) of this section must use a template that:

(a) Is standardized across all health plans offered by the carrier;

(b) Uses the United States pharmacopeia classification system;

(c) Organizes drugs by therapeutic class, listing drugs alphabetically; and

(d) Provides a separate list for drugs used to treat a serious illness covered under the plan's medical benefit.

(3) Each carrier offering or renewing a health plan on or after January 1, 2017, must make available to current and potential enrollees the information mandated under section (1) and (2).  The information must be available prior to the beginning of the open enrollment period and must be done via a public website and through a toll free number that is posted on the carrier’s website. 

(4) Each carrier offering or renewing a health plan on or after January 1, 2017, must, no later than thirty days after the offer or renewal date, attest to the office of the insurance commissioner that the carrier has satisfied the requirements of this section.

(5) The Commissioner of the Division of Insurance may adopt rules to implement this section.

(6) For purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under the health plan, including drugs covered under the plan's pharmacy benefit and medical benefit.

SECTION 5. Chapter 32A of the General Laws is hereby amended by inserting after section 23 the following section:-

Section 24. Any coverage offered by the commission to any active or retired employee of the commonwealth who is insured under the group insurance commission on or after January 1, 2017, shall:

(a) Post the formulary for the health plan on the carrier's web site in a manner that is accessible and searchable by enrollees, potential enrollees, and providers;

(b) Update the formulary posted pursuant to subsection (1)(a) of this section no later than twenty-four hours after making a change to the formulary; and

(c) Include on any published formulary for the plan, including but not limited to the formulary posted pursuant to subsection (1)(a) of this section, the following:

(i) Any utilization management edits –- including prior authorization, step therapy edits, quantity limits, or other requirements -- for each specific drug included in the formulary; and

(ii) For each drug included on the formulary and subject to a coinsurance, the range of cost sharing for a potential enrollee if the potential enrollee purchases the drug in person at an in-network pharmacy, as follows: 

(A) Under one hundred dollars: $;

(B) One hundred dollars to two hundred fifty dollars: $$;

(C) Two hundred fifty-one dollars to five hundred dollars: $$$; and

(D) Over five hundred dollars: $$$$. 

(iii) If the carrier allows the option for mail order pharmacy, the carrier separately must list the range of cost-sharing for a potential enrollee if the potential enrollee purchases the drug through a mail order facility utilizing the same ranges as provided in section (1)(c)(2).

(2) The formulary posted pursuant to subsection (1)(a) of this section must use a template that:

(a) Is standardized across all health plans offered by the carrier;

(b) Uses the United States pharmacopeia classification system;

(c) Organizes drugs by therapeutic class, listing drugs alphabetically; and

(d) Provides a separate list for drugs used to treat a serious illness covered under the plan's medical benefit.

(3) Each carrier offering or renewing a health plan on or after January 1, 2017, must make available to current and potential enrollees the information mandated under section (1) and (2).  The information must be available prior to the beginning of the open enrollment period and must be done via a public website and through a toll free number that is posted on the carrier’s website. 

(4) Each carrier offering or renewing a health plan on or after January 1, 2017, must, no later than thirty days after the offer or renewal date, attest to the office of the insurance commissioner that the carrier has satisfied the requirements of this section.

(5) The Commissioner of the Division of Insurance may adopt rules to implement this section.

(6) For purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under the health plan, including drugs covered under the plan's pharmacy benefit and medical benefit.