Amendment #621 to H4400

MassHealth Drug Pricing II

Representatives Jones of North Reading, Hill of Ipswich, Poirier of North Attleborough, Gifford of Wareham, Frost of Auburn and Smola of Warren move to amend the bill by adding the following section:-

“SECTION X. Notwithstanding any general or special law to the contrary,

(a) The executive office of health and human services may determine, subject to required federal approvals, the extent to which to include within MassHealth’s covered services federally-optional coverage of prescribed drugs.

(b) MassHealth may not exclude any drugs from coverage pursuant to subsection (a) unless the following conditions are met:

(1) the MassHealth Drug Utilization Review Board includes at least one member representative or advocate and at least one health economist; and

(2) MassHealth has established an exceptions process pursuant to which MassHealth may cover otherwise excluded drugs in unique circumstances.

(c) Subject to the requirements of subsection (b), MassHealth may only exclude a drug from coverage pursuant to subsection (a) if all of the following conditions have been met:

(1) the drug’s manufacturer has refused to agree with the executive office on a cost-effective price or a cost-effective value-based payment arrangement for the drug pursuant to Section 12A of chapter 118E of the general laws;

(2) the drug has been excluded from coverage in one or more of the group insurance commission’s benefits plans or by a national pharmacy benefits manager responsible for more than 10,000,000 lives;

(3) the drug’s exclusion is not based on the race, color, national origin, age, disability, religion, creed,  sexual orientation, or sex (including gender identity and gender stereotyping) of the member population benefitting from the drug;

(4) the MassHealth Drug Utilization Review Board has been consulted on the decision to exclude the drug;

(5) if the drug is an anti-psychotic or other behavioral health drug, the department of mental health has approved the drug’s exclusion; and

(6) MassHealth has provided an opportunity for public comment on the exclusion of the drug.

(d) Nothing in this section shall eliminate or reduce a MassHealth member’s right to appeal a coverage decision through the MassHealth Board of Hearings.”