SENATE DOCKET, NO. 375 FILED ON: 1/13/2023
SENATE . . . . . . . . . . . . . . No. 616
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
Julian Cyr
_________________
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 relating to patient cost, benefit and coverage information, choice, and price transparency.
_______________
PETITION OF:
NAME: DISTRICT/ADDRESS:
Julian Cyr Cape and Islands
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 SENATE DOCKET, NO. 375 FILED ON: 1/13/2023
SENATE . . . . . . . . . . . . . . No. 616
By Mr. Cyr, a petition (accompanied by bill, Senate, No. 616) of Julian Cyr for legislation
relative to patient cost, benefit and coverage information, choice, and price transparency.
Financial Services.
[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE SENATE, NO. 650 OF 2021-2022.]
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Third General Court
(2023-2024)
_______________
An Act relating to patient cost, benefit and coverage information, choice, and price transparency.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Chapter 94C of the General Laws, is hereby amended by inserting after
2 section 21C the following new section:-
3 Section 21D (a) For the purposes of this section, the following terms shall have the
4 following meanings unless the context clearly requires otherwise:
5 “Cost-sharing information”, the amount an enrollee is required to pay in order to receive
6 a drug that is covered under the enrollee’s health plan.
7 “Enrollee” a person who is receiving a health care benefit and assumes financial
8 responsibility for outstanding costs associated with a prescription drug to treat a health condition
9 for themself or a dependent member of their household.
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10 ''Health care benefit'', a full or partial payment for health care services or the right under a
11 contract or a certificate or policy of insurance to have a full or partial payment made by a health
12 plan, as defined in this section, for a specified health care service.
13 “Health plan” any insurance company authorized to provide health insurance in this state
14 or any legal entity which is self-insured and providing health care benefits to its employees.
15 “Interoperability element”, hardware, software, integrated technologies or related
16 licenses, technical information, privileges, rights, intellectual property, upgrades, or services that
17 may be necessary to provide the data set forth in subsection (b)(3) in the requested format and
18 consistent with subsection(b)(1).
19 “Patient” the enrollee or dependent family member of the enrollee who is treated by a
20 prescribing physician.
21 “Personal Representative” a person, who has been identified by the enrollee or by the
22 commonwealth on behalf of the enrollee, to assist with decision making during their medical
23 appointment, such as: a child accompanying an elderly parent, a healthcare proxy, a parent of a
24 minor child, or a spouse.
25 “Pharmacy benefit manager” (a) For the purposes of this section, the term ''pharmacy
26 benefit manager'' shall mean any person or entity that administers the (i) prescription drug,
27 prescription device or pharmacist services or (ii) prescription drug and device and pharmacist
28 services portion of a health benefit plan on behalf of plan sponsors, including, but not limited to,
29 self-insured employers, insurance companies and labor unions. A health benefit plan that does
30 not contract with a pharmacy benefit manager shall be considered a pharmacy benefit manager
31 for the purposes of this section, unless specifically exempted.
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32 “Prescribing practitioner” a physician, nurse practitioner, or physician’s assistant who
33 writes a prescription for a patient during the course of care for a medical condition.
34 (b) Any health plan or pharmacy benefit manager shall, upon request of the patient,
35 enrollee, their prescribing practitioner, or their personal representative, furnish the cost, benefit,
36 and coverage data set forth in subsection (3) to the enrollee, their prescribing practitioner, or
37 their personal representative and shall ensure that such cost, benefit, and coverage data is (i)
38 current as of one business day after any change is made; (ii) provided in real time; and (iii) in the
39 same format that the request is made by the enrollee or their prescribing practitioner.
40 (1) The format of the request shall use established industry content and transport
41 standards published by:
42 (i) a standards developing organization accredited by the American National Standards
43 Institute, included but not limited to, the National Council for Prescription Drug Programs, ASC
44 X12, Health Level 7; or
45 (ii) a relevant federal or state agency or government body, included but not limited to the
46 Center for Medicare & Medicaid Services or the Office of the National Coordinator for Health
47 Information technology, The Commonwealth of Massachusetts Department of Public Health,
48 Division of Insurance, Health Policy Commission, or Center for Health Information and
49 Analysis.
50 (2) A facsimile, proprietary payor or patient portal, or other electronic form other than as
51 required by section (b) shall not be considered acceptable electronic formats pursuant to this
52 section.
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53 (3) Upon such request, the following data shall be provided for any prescription drug
54 covered under the enrollee’s health plan:
55 (i) the patient’s current eligibility information for such prescription drug;
56 (ii) a list of any clinically-appropriate alternatives to such prescription drug covered
57 under the enrollee’s current health plan;
58 (iii) cost-sharing information for such prescription drug and such clinically-appropriate
59 alternatives, including a description of any variance in cost-sharing based on pharmacy, whether
60 retail or mailorder, or health care provider dispensing or administering such prescription drug or
61 such alternatives;
62 (iv) any applicable utilization management requirements for such prescription drug or
63 such clinically-appropriate alternatives, including prior authorization, step therapy, quantity
64 limits, and site-of-service restrictions
65 (4) Any health plan or pharmacy benefit manager shall furnish the data set forth in
66 subsection (b)(3), whether the request is made using the prescription drug’s unique billing code,
67 such as a National Drug Code or Healthcare Common Procedure Coding System code or
68 descriptive term, such as the brand or generic name of the prescription drug.
69 (i) A health plan or pharmacy benefit manager shall not deny or delay a request as a
70 method of blocking the data set forth in subsection (b)(3) from being shared based on how the
71 drug was requested.
72 (c) Any health plan or pharmacy benefit manager furnishing the data set forth in
73 subsection (b)(3), shall not:
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74 (1) restrict, prohibit, or otherwise hinder, in any way, a prescribing practitioner or health
75 care professional from communicating or sharing:
76 (i) any of the data set forth in subsection (b)(3);
77 (ii) additional information on any lower-cost or clinically-appropriate alternatives,
78 whether or not they are covered under the enrollee’s plan; or
79 (iii) additional payment or cost-sharing information that may reduce the patient’s out-of-
80 pocket costs, such as cash price or patient assistance and support programs whether sponsored by
81 a manufacturer, foundation, or other entity;
82 (2) Except as may be required by law, interfere with, prevent, or materially discourage
83 access, exchange, or use of the data set forth in subsection (b)(3), which may include charging
84 fees, not responding to a request at the time made where such a response is reasonably possible,
85 implementing technology in nonstandard ways or instituting enrollee consent requirements,
86 processes, policies, procedures, or renewals that are likely to substantially increase the
87 complexity or burden of accessing, exchanging, or using such data; nor
88 (3) penalize a prescribing practitioner or professional for disclosing such information to
89 an enrollee or their personal representative, or for prescribing, administering, or ordering a
90 clinically appropriate or lower-cost alternative.
91 (4) Any health plan or pharmacy benefit manager shall treat an enrollee’s identified
92 personal representative as the enrollee for purposes of this section.
93 (5) If under applicable law a person has authority to act on behalf of an enrollee in
94 making decisions related to health care, a health plan or pharmacy benefit manager, or its
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95 affiliates or entities acting on its behalf, must treat such person as a personal representative under
96 this section.
97 (d) Reimbursement for fees imposed for data access pursuant to this section may be
98 negotiated and contracted between a health plan or pharmacy benefit manager and a prescribing
99 provider upon mutual agreement
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