HOUSE DOCKET, NO. 1505        FILED ON: 1/16/2019

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 969

 

The Commonwealth of Massachusetts

_________________

PRESENTED BY:

Jennifer E. Benson

_________________

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:

Date Added:

Jennifer E. Benson

37th Middlesex

1/16/2019

Bud L. Williams

11th Hampden

1/23/2019

Steven Ultrino

33rd Middlesex

1/24/2019

Stephan Hay

3rd Worcester

1/24/2019

David Allen Robertson

19th Middlesex

1/26/2019

Tram T. Nguyen

18th Essex

1/26/2019

Danielle W. Gregoire

4th Middlesex

1/28/2019

Tackey Chan

2nd Norfolk

1/28/2019

Christina A. Minicucci

14th Essex

1/29/2019

Elizabeth A. Malia

11th Suffolk

1/29/2019

David M. Rogers

24th Middlesex

1/29/2019

William L. Crocker, Jr.

2nd Barnstable

1/29/2019

Bruce E. Tarr

First Essex and Middlesex

1/30/2019

John Barrett, III

1st Berkshire

1/30/2019

Patrick M. O'Connor

Plymouth and Norfolk

1/30/2019

Mathew J. Muratore

1st Plymouth

1/30/2019

Paul McMurtry

11th Norfolk

1/30/2019

Mike Connolly

26th Middlesex

1/30/2019

James B. Eldridge

Middlesex and Worcester

1/30/2019

Carlos González

10th Hampden

1/30/2019

Daniel J. Ryan

2nd Suffolk

1/30/2019

Natalie M. Higgins

4th Worcester

1/31/2019

Thomas A. Golden, Jr.

16th Middlesex

1/31/2019

Brendan P. Crighton

Third Essex

1/31/2019

Denise C. Garlick

13th Norfolk

1/31/2019

Denise Provost

27th Middlesex

1/31/2019

Carmine Lawrence Gentile

13th Middlesex

2/1/2019

Ruth B. Balser

12th Middlesex

2/1/2019

Jay D. Livingstone

8th Suffolk

2/1/2019

John C. Velis

4th Hampden

2/1/2019

Marjorie C. Decker

25th Middlesex

2/1/2019

Daniel R. Cullinane

12th Suffolk

2/1/2019

Joseph W. McGonagle, Jr.

28th Middlesex

2/1/2019

Sean Garballey

23rd Middlesex

2/1/2019

Jon Santiago

9th Suffolk

2/1/2019

Paul W. Mark

2nd Berkshire

2/1/2019

William C. Galvin

6th Norfolk

2/1/2019

Bruce J. Ayers

1st Norfolk

2/1/2019

James Arciero

2nd Middlesex

2/1/2019

Linda Dean Campbell

15th Essex

2/1/2019

Kay Khan

11th Middlesex

2/1/2019

David Biele

4th Suffolk

2/1/2019

Jack Patrick Lewis

7th Middlesex

2/1/2019

Carolyn C. Dykema

8th Middlesex

2/1/2019


HOUSE DOCKET, NO. 1505        FILED ON: 1/16/2019

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 969

By Ms. Benson of Lunenburg, a petition (accompanied by bill, House, No. 969) of Jennifer E. Benson and others relative to healthcare policies, contracts, agreements, plans or certificate of insurance.  Financial Services.

 

The Commonwealth of Massachusetts

 

_______________

In the One Hundred and Ninety-First General Court
(2019-2020)

_______________

 

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:
 

SECTION 1. Chapter 175 of the General Laws is hereby amended by inserting after section 47II the following section:-

Section 47JJ.

(a) Any policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth on or after January 1, 2018, shall:

(1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding whether the plan uses a formulary.  The notice shall include an explanation of what a formulary is, how the plan determines which prescription drugs are included or excluded, and how often the plan reviews the contents of the formulary.

(2) Post the formulary or formularies for each product offered by the plan on the plan’s internet web site in a manner that is accessible and searchable by potential enrollees, enrollees, and providers.

(3) Update the formularies posted pursuant to paragraph (2) with any change to those formularies within 72 hours after making the change.

(4) Use a standard template developed pursuant to subsection (b) to display the formulary or formularies for each product offered by the plan.

(5) Include all of the following on any published formulary for any product offered by the plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):

(i) Any prior authorization, step therapy requirements, or utilization management requirements for each specific drug included on the formulary.

(ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier in the evidence of coverage.

(iii) For prescription drugs covered under the plans medical benefit and typically administered by a provider, plans must disclose to enrollees and potential enrollees, all covered drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that is staffed at least during normal business hours.

(iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is subject to a coinsurance and dispensed at an in-network pharmacy the plan must:

(A) disclose the dollar amount of the enrollee’s cost-sharing, or

(B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of each specific drug included on the formulary, as follows:

Under $100 – $.

$100-$250 – $$.

$251-$500 – $$$.

$500-$1,000 – $$$$.

Over $1,000 -- $$$$$

(v) 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 subclause (B).

(vi) A description of how medications will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs that may not apply to the

deductible for a medication.

(b) The Division of Insurance shall develop a standard formulary template which a health care service plan shall use to comply with paragraph (4).

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

Section 8LL.

(a) 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, 2018, shall:

(1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding whether the plan uses a formulary.  The notice shall include an explanation of what a formulary is, how the plan determines which prescription drugs are included or excluded, and how often the plan reviews the contents of the formulary.

(2) Post the formulary or formularies for each product offered by the plan on the plan’s internet web site in a manner that is accessible and searchable by potential enrollees, enrollees, and providers.

(3) Update the formularies posted pursuant to paragraph (2) with any change to those formularies within 72 hours after making the change.

(4) Use a standard template developed pursuant to subsection (b) to display the formulary or formularies for each product offered by the plan.

(5) Include all of the following on any published formulary for any product offered by the plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):

(i) Any prior authorization, step therapy requirements, or utilization management requirements for each specific drug included on the formulary.

(ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier in the evidence of coverage.

(iii) For prescription drugs covered under the plans medical benefit and typically administered by a provider, plans must disclose to enrollees and potential enrollees, all covered drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that is staffed at least during normal business hours.

(iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is subject to a coinsurance and dispensed at an in-network pharmacy the plan must:

(A) disclose the dollar amount of the enrollee’s cost-sharing, or

(B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of each specific drug included on the formulary, as follows:

Under $100 – $.

$100-$250 – $$.

$251-$500 – $$$.

$500-$1,000 – $$$$.

Over $1,000 -- $$$$$

(v) 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 subclause (B).

(vi) A description of how medications will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs that may not apply to the deductible for a medication.

(b) The Division of Insurance shall develop a standard formulary template which a health care service plan shall use to comply with paragraph (4).

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

Section 4LL.

(a) Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth on or after January 1, 2018, shall:

(1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding whether the plan uses a formulary.  The notice shall include an explanation of what a formulary is, how the plan determines which prescription drugs are included or excluded, and how often the plan reviews the contents of the formulary.

(2) Post the formulary or formularies for each product offered by the plan on the plan’s internet web site in a manner that is accessible and searchable by potential enrollees, enrollees, and providers.

(3) Update the formularies posted pursuant to paragraph (2) with any change to those formularies within 72 hours after making the change.

(4) Use a standard template developed pursuant to subsection (b) to display the formulary or formularies for each product offered by the plan.

(5) Include all of the following on any published formulary for any product offered by the plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):

(i) Any prior authorization, step therapy requirements, or utilization management requirements for each specific drug included on the formulary.

(ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier in the evidence of coverage.

(iii) For prescription drugs covered under the plans medical benefit and typically administered by a provider, plans must disclose to enrollees and potential enrollees, all covered drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that is staffed at least during normal business hours.

(iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is subject to a coinsurance and dispensed at an in-network pharmacy the plan must:

(A) disclose the dollar amount of the enrollee’s cost-sharing, or

(B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of each specific drug included on the formulary, as follows:

Under $100 – $.

$100-$250 – $$.

$251-$500 – $$$.

$500-$1,000 – $$$$.

Over $1,000 -- $$$$$

(v) 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 subclause (B).

(vi) A description of how medications will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs that may not apply to the deductible for a medication.

(b) The Division of Insurance shall develop a standard formulary template which a health care service plan shall use to comply with paragraph (4).

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

Section 4DD.

(a) Any individual or group health maintenance contract issued on or after January 1, 2018, shall:

(1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding whether the plan uses a formulary. The notice shall include an explanation of what a formulary is, how the plan determines which prescription drugs are included or excluded, and how often the plan reviews the contents of the formulary.

(2) Post the formulary or formularies for each product offered by the plan on the plan’s internet web site in a manner that is accessible and searchable by potential enrollees, enrollees, and providers.

(3) Update the formularies posted pursuant to paragraph (2) with any change to those formularies within 72 hours after making the change.

(4) Use a standard template developed pursuant to subsection (b) to display the formulary or formularies for each product offered by the plan.

(5) Include all of the following on any published formulary for any product offered by the plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):

(i) Any prior authorization, step therapy requirements, or utilization management requirements for each specific drug included on the formulary.

(ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier in the evidence of coverage.

(iii) For prescription drugs covered under the plans medical benefit and typically administered by a provider, plans must disclose to enrollees and potential enrollees, all covered drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that is staffed at least during normal business hours.

(iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is subject to a coinsurance and dispensed at an in-network pharmacy the plan must:

(A) disclose the dollar amount of the enrollee’s cost-sharing, or

(B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of each specific drug included on the formulary, as follows:

Under $100 – $.

$100-$250 – $$.

$251-$500 – $$$.

$500-$1,000 – $$$$.

Over $1,000 -- $$$$$

(v) 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 subclause (B).

(vi) A description of how medications will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs that may not apply to the deductible for a medication.

(b) The Division of Insurance shall develop a standard formulary template which a health care service plan shall use to comply with paragraph (4).

SECTION 5. Chapter 32A of the General Laws is hereby amended by inserting after section 27 the following section:- 

Section 28.

(a) 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, 2018, shall:

(1) Provide notice in the evidence of coverage and disclosure form to enrollees regarding whether the plan uses a formulary.  The notice shall include an explanation of what a formulary is, how the plan determines which prescription drugs are included or excluded, and how often the plan reviews the contents of the formulary.

(2) Post the formulary or formularies for each product offered by the plan on the plan’s internet web site in a manner that is accessible and searchable by potential enrollees, enrollees, and providers.

(3) Update the formularies posted pursuant to paragraph (2) with any change to those formularies within 72 hours after making the change.

(4) Use a standard template developed pursuant to subsection (b) to display the formulary or formularies for each product offered by the plan.

(5) Include all of the following on any published formulary for any product offered by the plan, including, but not limited to, the formulary or formularies posted pursuant to paragraph (2):

(i) Any prior authorization, step therapy requirements, or utilization management requirements for each specific drug included on the formulary.

(ii) If the plan uses a Tier-based formulary, the plan shall specify for each drug listed on the formulary the specific Tier the drug occupies and list the specific co-payments for each Tier in the evidence of coverage.

(iii) For prescription drugs covered under the plans medical benefit and typically administered by a provider, plans must disclose to enrollees and potential enrollees, all covered drugs and the dollar cost-sharing imposed on such drugs. This information can be provided to the consumer as part of the plan’s formulary pursuant to paragraph (2) or via a toll free number that is staffed at least during normal business hours.

(iv) For each prescription drug included on the formulary under clauses (ii) or (iii) that is subject to a coinsurance and dispensed at an in-network pharmacy the plan must:

(A) disclose the dollar amount of the enrollee’s cost-sharing, or

(B) the plan can provide a dollar amount range of cost sharing for a potential enrollee of each specific drug included on the formulary, as follows:

Under $100 – $.

$100-$250 – $$.

$251-$500 – $$$.

$500-$1,000 – $$$$.

Over $1,000 -- $$$$$

(v) 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 subclause (B).

(vi) A description of how medications will specifically be included in or excluded from the deductible, including a description of out-of-pocket costs that may not apply to the deductible for a medication.

(b) The Division of Insurance shall develop a standard formulary template which a health care service plan shall use to comply with paragraph (4).