MA H1125

Health carriers, benefit plans, and utilization review organizations are prohibited from limiting or excluding coverage of prescription drugs for patients who are medically stable on their current medication, as determined by their prescribing health care professional

Prohibited practices include reducing maximum drug coverage, increasing cost sharing, moving drugs to more restrictive formulary tiers, or removing drugs from formularies (unless FDA safety concerns or manufacturer discontinuation)

Coverage exemption requests must be responded to within 72 hours (24 hours for exigent circumstances); if no response is received, the exemption is automatically granted

Appeals of denied coverage exemptions must be decided within 72 hours (24 hours for urgent cases); failure to respond results in automatic approval of the exemption

Applies to health benefit plans delivered, issued, continued, or renewed on or after January 1, 2026, and amends Chapters 175, 176A, 176B, and 176G of the General Laws