MA H4491

Health carriers, health 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, if the drug was previously approved and prescribed within the past six months

"Nonmedical switching" is defined as mid-plan-year or open-enrollment formulary changes that force stable patients to switch to less costly alternative drugs, including reducing maximum coverage, increasing cost sharing, moving drugs to more restrictive tiers, or removing drugs from formularies

Coverage exemption requests must be responded to within 72 hours (24 hours for exigent circumstances), and failure to respond within the deadline results in automatic approval of the exemption

Appeals of denied coverage exemptions must be decided within 72 hours (24 hours for urgent cases), with automatic reversal if no decision is made; denials upheld on appeal may be submitted for external review under Chapter 514J

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