An Act relating to patient choice in dispensing of clinician-administered drugs

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Bill H.1313

SECTION 1. Chapter 176O of the General Laws is hereby amended by inserting after section 29 the following section:-

Section 30. (a) In this section:

(1) "Clinician-administered drug" means an outpatient prescription drug other than a vaccine that:

(A) cannot reasonably be self-administered by the patient to whom the drug is prescribed or by an individual assisting the patient with the self-administration; and

(B) is typically administered:

(i) by a health care provider authorized under the laws of this state to administer the drug, including when acting under a physician ’s delegation and supervision; and

(ii) in a physician’s office, hospital outpatient infusion center, or other clinical setting.

(b) A health benefit carrier:

(1) shall not refuse to authorize, approve, or pay a participating provider for providing covered clinician-administered drugs and related services to covered persons;

(2) shall not impose coverage or benefits limitations, or require an enrollee to pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or

other penalty when obtaining clinician-administered drugs from a health care provider authorized under the laws of this state to administer clinician-administered drugs, or a pharmacy;

(3) shall not interfere with the patient's right to choose to obtain a clinician-administered drug from their provider or pharmacy of choice, including inducement, steering, or offering financial or other incentives;

(4) shall not require clinician-administered drugs to be dispensed by a pharmacy selected by the health plan;

(5) shall not limit or exclude coverage for a clinician-administered drug when not dispensed by a pharmacy selected by the health plan, if such drug would otherwise be covered;

(6) shall not reimburse at a lesser amount clinician-administered drugs dispensed by a pharmacy not selected by the health plan;

(7) shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to a participating provider for providing covered clinician-administered drugs and related services to covered persons when all criteria for medical necessity are met, because the participating provider obtains clinician-administered drugs from a pharmacy that is not a participating provider in the health benefit issuer’s network;

(8) shall not require that an enrollee pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-administered drugs when not dispensed by a pharmacy selected by the health plan;

(9) shall not require a specialty pharmacy to dispense a clinician-administered medication directly to a patient with the intention that the patient will transport the medication to a healthcare provider for administration

(c) A health benefit carrier may offer, but shall not require:

(1) the use of a home infusion pharmacy to dispense clinician-administered drugs to patients in their homes or;

(2) the use of an infusion site external to a patient’s provider office or clinic.

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