Bill > S541

This bill aims to reduce out-of-pocket expenses for prescription drugs by establishing new regulations for health insurance plans. It prohibits insurance policies from imposing cost-sharing, which refers to any out-of-pocket expense like copayments or deductibles, exceeding one hundred dollars per thirty-day supply of a covered prescription drug. Additionally, it prevents plans from placing all drugs within a specific class into the highest cost-sharing tier of a tiered formulary, which is a list of covered drugs organized into different cost levels. These provisions apply before a deductible is met and also to high-deductible health plans once their minimum deductible amounts are satisfied. The bill also mandates that health plans allow enrollees to request an exception to the formulary if their prescribing physician determines that a formulary drug would be less effective or cause adverse effects compared to a non-formulary drug for the same condition; denials of these exceptions will be subject to the health plan's internal review process. Importantly, this bill does not require health plans to cover additional drugs, implement specific management techniques like prior authorization, or stop using tiered cost-sharing structures for other purposes. These new rules will apply to various types of health insurance, including those regulated under Chapters 175, 176A, 176B, and 176G of the General Laws, with an exception for catastrophic plans as defined in Chapter 176J.