SENATE, No. 614

SECTION 1.     Chapter 19A of the General Laws is hereby amended by adding at the end thereof the following new section: -

Section 41. EQUITY IN PROVISION OF PRESCRIPTION DRUG COVERAGE IN GENERAL - A health plan, and a health insurance issuer offering health insurance coverage, that provides for mail-order prescription drug coverage (as defined in paragraph (3)(A)) shall also provide non-mail-order prescription drug coverage consistent with paragraph (2).
    (2) EQUITABLE COVERAGE - A plan or coverage provides non-mail-order prescription drug coverage consistent with this paragraph only if-
    (A) benefits under the non-mail-order prescription coverage are provided for in the case of all drugs and all circumstances under which benefits are provided under the mail-order prescription drug coverage,
    (B) no deductible or similar cost-sharing is imposed with respect to benefits under the non-mail-order prescription drug coverage unless such a deductible or similar cost-sharing is imposed with respect to benefits under the mail-order prescription drug coverage; and
    (C) the benefits for the non-mail-order coverage assures payments consistent with either (or both) of the following clauses:
    1) The dollar amount of payment for prescription drug coverage is not less than the dollar amount of benefits provided with respect to the mail-order coverage for that same coverage.
    2) The cost-sharing (including deductibles, copayments, or coinsurance) imposed with respect to non-mail-order coverage is not greater (as a percentage of charges or dollar amount, as specified under the coverage) than the cost-sharing imposed with respect to the mail-order coverage.
    (3) DEFINITIONS - For purposes of this subsection:
    (A) MAIL-ORDER PRESCRIPTION DRUG COVERAGE - The term "mail-order prescription drug coverage" means provision of benefits for prescription drugs and biologicals that are delivered directly to participants and beneficiaries through the mail or similar means.
    (B) NON-MAIL-ORDER PRESCRIPTION DRUG COVERAGE - The term "non-mail-order prescription drug coverage" means the provision of benefits for prescription drugs and biologicals through one or more local pharmacies.
    (D) HEALTH PLAN - The term "health plan" means an accident and health insurance policy or certificate; a nonprofit hospital or medical service corporation contract; a health maintenance organization subscriber contract; a plan provided by a multiple employer welfare arrangement; a Medicare+Choice plan; Medigap and Medicare Select Policies; or a plan provided by another benefit arrangement, to the extent permitted by the Employee Retirement Income Security Act of 1974, as amended, or by any waiver of or other exception to that Act provided under federal law or regulation. Without limitation, "health plan" does not mean any of the following types of insurance: Accident, Credit, Disability income, Specified disease, Dental or vision, Coverage issued as a supplement to liability insurance, Medical payments under automobile or homeowners, Insurance under which benefits are payable with or without regard to fault and is statutorily required to be contained in any liability policy or equivalent self-insurance, and Hospital indemnity policy or certificate.
    (b) PROHIBITIONS - A health plan as defined in paragraph (3)(D), may not provide monetary payments or rebates to an individual to encourage such individual to accept less than the minimum protections available under this section.
    (c) CONSTRUCTION - Nothing in this section shall be construed as preventing a plan or issuer from -
    (1) restricting the drugs for which benefits are provided under the plan of health insurance coverage, or
    (2) imposing a limitation on the amount of benefits provided with respect to such coverage or the cost-sharing that may he imposed with respect to such coverage, so long as such restrictions and limitations are consistent with subsection (a).
    (d) NOTICE. - A health plan under this part shall comply with the notice requirement under the Employee Retirement Income Security Act of 1974 with respect to the requirements of this section as it such section applied to such plan.