Bill
H 4488
Massachusetts PBMs must ensure MAC lists reflect market prices, provide timely updates and appeals, and prevent lower reimbursements to independent pharmacies.
Status and procedural history
- Bill Number: H 4488 (Commonwealth of Massachusetts)
- Introduced: September 18, 2025; filed 9/8/2025.
- Committee actions (9/18/2025): Reported from the House Committee on Financial Services, reported favorably and referred to the Committee on Health Care Financing. The bill is presented as “Introduced and adopted” in the provided materials.
Note on content inconsistency
- The header lists the title “Joseph Hayne Rainey,” and the packet also includes text of a South Carolina House resolution honoring Joseph Hayne Rainey (filed May 6, 2025). However, the substantive Massachusetts bill text that follows is an act regulating pharmacy benefits manager (PBM) handling of maximum allowable cost (MAC) lists and reimbursements to pharmacies. This summary focuses on the Massachusetts PBM legislation text.
Purpose and intent
- To increase transparency and procedural protections for pharmacies regarding PBM maximum allowable cost (MAC) lists, ensure MAC-based reimbursements are grounded in market availability, provide timely updates and an administrative appeals process, and prevent PBMs from reimbursing independent pharmacies at lower rates than PBM-affiliated pharmacies. The law also applies to PBMs contracted by MassHealth and the Group Insurance Commission (GIC).
Key provisions and changes
- Definitions: establishes terms including “maximum allowable cost list,” “pharmacy acquisition cost,” “pharmacy benefits manager (PBM),” “pharmacy,” “pharmacist,” and “pharmacy benefits manager affiliate.”
- MAC inclusion criteria: a drug must be FDA Orange/Green Book A/B-rated (or equivalent rating by Medi-span/Elsevier/etc.), available for purchase from national/regional wholesalers doing business in the Commonwealth, and not obsolete.
- Access and update requirements:
- PBMs must provide pharmacies access to their MAC lists.
- PBMs must update MAC lists within 7 calendar days after (a) a ≥10% increase in pharmacy acquisition cost observed among at least 60% of wholesalers doing business in the Commonwealth, (b) a methodology change, or (c) a change in a methodology variable.
- PBMs must notify pharmacies promptly of updates.
- Administrative appeals and timing:
- PBMs must provide a reasonable administrative appeal procedure (dedicated phone/email/website). Pharmacies have at least 7 business days to file an appeal.
- PBMs must respond to appeals within 7 business days.
- If an appeal is upheld, PBMs must revise the MAC within 7 business days, allow reverse/rebill of affected claims, provide the NDC underlying the MAC change, and apply the change to similarly situated pharmacies.
- If denied, PBMs must provide the NDC and names of wholesalers with the drug in stock below the MAC.
- If the pharmacy’s primary wholesaler cannot supply the drug below the MAC, the PBM must raise the MAC above that pharmacy’s acquisition cost and allow reverse/rebill for affected claims.
- Parity with PBM affiliates: PBMs may not reimburse a pharmacy or pharmacist at a lower per-unit amount than they reimburse a PBM affiliate for the same pharmacist services (calculated by generic product identifier/generic code).
- Right to decline: A pharmacy may decline to dispense if reimbursement under a MAC list would pay less than the pharmacy’s acquisition cost.
- Scope: Applies to PBMs serving MassHealth or the GIC when those entities engage PBMs to maintain MAC lists.
- Enforcement: Violations are treated as deceptive and unfair trade practices under Chapter 93A (allowing private civil enforcement and attorney general authority).
Who is affected
- Community and independent pharmacies and pharmacists (directly affected).
- Pharmacy benefit managers and their affiliates (regulated).
- Pharmaceutical wholesalers (identified as sources for pricing/availability).
- Payors including MassHealth and the GIC (when they contract PBM services).
- Patients may be indirectly affected through access to medications and pharmacy willingness to dispense.
Potential impacts and considerations
- Likely increases transparency and procedural recourse for pharmacies challenging MACs; may reduce situations where pharmacies are reimbursed below acquisition cost.
- Could increase administrative burden on PBMs (timely updates, appeal processes, documentation).
- May shift costs among PBMs, payors, and pharmacies depending on adjustments to MACs and dispensing behavior.
- Enforcement under Chapter 93A creates a route for civil claims and regulatory scrutiny.
Timelines and operational deadlines
- PBMs: 7 calendar days to update MACs after specified triggers; 7 business days for appeal filing window and for PBM responses and corrective actions once an appeal is received.
Compiled from official sources — confirm details with the bill’s official record.
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