Patients would pay no more than $25 for certain brand-name drugs to treat chronic diseases, including insulin for diabetes, and would have no cost for similar generic options under a compromise bill that the House and Senate presented to Governor Maura Healey’s desk on Monday. .
The bill that emerged from months of private talks Friday afternoon would also add scrutiny to pharmacy benefit managers and eliminate or limit out-of-pocket costs for drugs that treat certain chronic conditions.
Branches sent the bill to Healey with just one day left in the two-year deadline, leaving only hours to resolve potential differences and likely giving Healey only two options: sign it or let it die by pocket veto .
The bill requires MassHealth, the Group Insurance Commission, which covers state employees, retirees and their dependents, and other insurers to provide coverage for one generic drug and one brand-name drug for each of the following: diabetes, asthma and the two most common. heart conditions
Patients treated for these conditions should not share any of the cost of a generic drug, including through copayments, coinsurance, or a deductible. The selected brand-name drug would not be subject to any deductibles or coinsurance, and copayments would be capped at $25, according to a bill summary.
“The last time we looked, that’s about 180,000 people who will be affected by this change, which means they will have access to these drugs,” Sen. Cindy Friedman, the bill’s lead negotiator, said during the session of monday
Friedman, who in her time as co-chair of the Health Care Financing Committee called on powerful industry players to embrace reforms, previously said she does not “assume that these will mean higher costs for insurers” in limit cost-sharing for chronic disease. disease treatments.
Language in the Senate bill to limit what patients pay for “delivery mechanisms” to manage chronic diseases, such as needles, inhalers and monitors, was not included in the final compromise, a Friedman aide said.
The Senate passed its version of the bill in November 2023. The House passed its bill in late July 2024.
The bill would also create a licensing process for pharmacy benefit managers, which have been under scrutiny for their role in brokering drug transactions.
PBMs negotiate transactions between insurers, manufacturers and pharmacies, and argue that their work lowers costs for consumers. Critics say PBMs operate with little oversight and are responsible for rising costs.
Under the compromise, the Division of Insurance would license and regulate PBMs in Massachusetts. It would also prohibit a PBM from making payments to a pharmacy benefit consultant or broker if there is a conflict of interest.
According to the bill’s summary, the Center for Health Information and Analysis would be authorized to collect data on PBMs and issue regulations to better collect the information and help the state understand the drivers of prescription drug cost growth.
“It takes the first step in understanding the role that pharmacy benefit managers play in the delivery of the health care system and the effect that has on cost and, again, on access,” Friedman said.
Rich Pezzillo, executive director of the New England Hemophilia Association and co-leader of the Patients for Prescription Access coalition, said PBMs “have been allowed to operate under the radar for too long.”
“Through their underwriting tactics and their hidden middleman position, PBMs have directly compromised patient care and access to much-needed treatments,” Pezzillo said. “We hope that with the oversight and transparency mandates included in the bill, PBMs will be forced to show their cards and patients will have greater access to the drugs they depend on and will be able to pay better. We look forward to working with lawmakers in 2025 to build on this legislation and further protect patients by passing a ban on copay accumulators and ensuring that PBM discounts are passed on to consumers.”
The bill also tries to ensure that patients who buy prescription drugs at a pharmacy don’t pay more through cost-sharing, using a co-pay or deductible, if it’s cheaper for them to buy them directly, Friedman said.
The new cost-sharing limits for drugs used to treat diabetes, asthma and heart conditions will go into effect on July 1, 2025. The bill gives the insurance commissioner until July 1 October 2025 to release regulations for PBMs, which should begin. due on January 1, 2026.
The bill would create an Office of Pharmaceutical Policy and Analysis within the Health Policy Commission to analyze trends related to pharmaceutical access, affordability and spending. It also authorizes the HPC to evaluate pharmaceutical manufacturing companies and PBMs.
Pharmaceutical manufacturers and PBMs should attend the HPC’s annual cost growth benchmark hearing, where the commission sets a statutory rate of health care cost growth based on expert testimony, although that the HPC does not have the power to enforce the consequences to overcome this cost growth.
“We welcome efforts to bring real transparency to drug prices,” said a statement from Save Our Benefits MA, a coalition of unions and business groups trying to lower insurance prices. “Big Pharma has spent big at the expense of consumers by blaming others for rising drug prices while lining their pockets. Allowing the HPC to take the time to really look at where pharmaceutical costs originate is a win for Massachusetts consumers.”
Sen. Bruce Tarr of Gloucester, who was on the conference committee that negotiated the final bill, said during Monday’s session that Senate-passed protections for independent pharmacists were left out of the bill.
“My hope is that we continue to consider in the future the expanded role that pharmacists are playing in the delivery of health care to ensure that it is properly recognized and adequately compensated. And this bill does not include provisions to that effect. I intend to introduce them in the new session,” Tarr said.
Friedman thanked him for raising the issue.
“We couldn’t move this, it’s very important. It’s especially important that we maintain the creditworthiness and stability of our independent pharmacists who provide such critical care, especially around packaging and compounding for many of our group homes and people in rural communities and so on.” said Friedman. “I want to make a real move about it, too.”
Senate-passed prescription drug pricing bills died in each of the last two sessions without votes in the House, where Democrats focused on trying to overhaul the process for reviewing hospital expansions.
The drug reform bill was negotiated this year as a parallel “package,” Friedman said, with a hospital oversight bill that was also released from committee Friday and approved by the branches on Monday.