Massachusetts is taking a significant step forward in the fight to rein in pharmacy benefit manager (PBM) practices that have long threatened the viability of independent and community pharmacies. House Bill 4493 (HB 4493), titled “An Act to Ensure Access to Prescription Medication and Community Pharmacies,” was recommended for passage by committee and referred to the House Ways and Means Committee on August 4, 2026.
The bill addresses critical issues facing Massachusetts pharmacies, including below-cost reimbursement, anti-competitive pharmacy steering, and unfair audit practices. If enacted, HB 4493 would amend current Massachusetts law governing contracts for community pharmacy services. Massachusetts pharmacies should reach out to their state legislators and urge them to pass the bill.
Key Provisions of Massachusetts HB 4493
Fair Reimbursement and Prohibition of Retroactive Rate Reductions
At the heart of HB 4493 is its proposed requirement that contracts between PBMs and pharmacies include a dispensing fee no less than what is paid by the Massachusetts Medicaid Program. The bill also would prohibit retroactive discounts and the use of “Generic Effective Rate,” “Brand Effective Rate,” or any similar retroactive rate reductions. Importantly, payments to non-affiliated pharmacies must be equal to or greater than payments to PBM-affiliated pharmacies, directly targeting the two-tiered reimbursement structures that can disadvantage independent pharmacies.
Anti-Steering Protections
Similar to the growing trend of PBM reform efforts throughout the United States, HB 4493 would explicitly prohibit PBMs from engaging in “pharmacy steering,” or channeling prescriptions to pharmacies in which a PBM or carrier has an ownership interest, including retail, mail-order, or specialty pharmacies. This aligns with the FTC’s landmark 2024 interim report documenting how PBM-affiliated pharmacies have leveraged formulary design and differential reimbursement to capture a disproportionate share of prescription volume.
Specialty Pharmacy Network Access
If passed, the bill would require PBMs to allow any Massachusetts-licensed pharmacy to provide any medication, including specialty medications, provided it meets the same service requirements as other pharmacies. The bill further provides that requirements for providing specialty medications could not be designed to exclude independent pharmacies, a powerful protection against the burdensome credentialing requirements that have systematically excluded independent pharmacies from lucrative specialty networks.
Maximum Allowable Cost (MAC) Pricing Protections
HB 4493 would also establish comprehensive maximum allowable cost (MAC) pricing safeguards, including a Medicaid-floor reimbursement standard, nondiscrimination requirements for non-affiliated pharmacies, drug eligibility standards tied to FDA Orange Book ratings and wholesaler availability, and mandatory MAC list updates every three business days with payments recalculated within two business days.
Robust Appeals Process
The legislation would also establish a clearly defined MAC appeals process. Under HB 4493, pharmacies would be able to contest pricing when costs fall below the Medicaid Program rate or when drugs do not meet eligibility requirements. PBMs must resolve appeals within seven business days, and if a pharmacy’s appeal is valid, the PBM must retroactively adjust costs and reprocess all claims from the date of the appeal, extending the adjustment to all similar pharmacies in the network within three business days. Pharmacy Services Administrative Organizations (PSAOs) would also be able to file appeals on behalf of pharmacies or groups of pharmacies.
Additional PBM Audit and Contracting Protections
As currently drafted, HB 4493 also includes important pharmacy audit reform. During audits, if a pharmacy could validate the intent of a prescription through signature logs or statements from the prescriber and provided the intended medication with only a clerical error (with no financial or clinical impact), the PBM could only recoup the dispensing fee, not the ingredient cost. All audit revenue would be returned to the plan sponsor. The bill would also prohibit PBMs from charging community pharmacies for credentialing, bars PBMs from requiring brand-name drugs where generics are readily available, and require annual reporting to the Insurance Commissioner on denied pharmacy appeals.
Massachusetts’ Existing PBM Regulatory Framework
HB 4493 builds upon a growing body of Massachusetts law aimed at increasing oversight and accountability of PBMs operating in the Commonwealth.
For instance, effective January 1, 2026, Massachusetts passed legislation that established mandatory PBM licensing through the Division of Insurance, conflict-of-interest disclosure requirements, detailed cost and pricing data reporting to the Center for Health Information and Analysis (CHIA), and financial assessments on PBMs based on Massachusetts market share. The law also established the Office of Pharmaceutical Policy and Analysis (OPPA) within the Health Policy Commission to monitor and analyze pharmaceutical spending trends.
Additionally, the statute HB 4493 would amend, Section 226A of Chapter 175 of the General Laws, provides audit protections including advance notice requirements, a two-year lookback limit, actual-overpayment-based findings, a 30-day appeals window, and prohibition of percentage-based auditor compensation.
While Massachusetts already has significant protections related to PBM transparency and licensing, HB 4493 would significantly expand this statute by adding comprehensive reimbursement, pricing, and network access provisions.
Why HB 4493 Matters for Massachusetts Community Pharmacies
Taken together, HB 4493, if passed, and the existing regulatory framework position Massachusetts to have one of the most comprehensive frameworks for PBM oversight in the country. While the 2025 Act addressed licensing, transparency, and consumer cost-sharing, HB 4493 would address critical gaps in that Act by targeting some of the contract-level practices that directly impact independent pharmacy viability.
Massachusetts HB 4493 also arrives at a pivotal moment for PBM regulation nationally. The Consolidated Appropriations Act of 2026 gave CMS new authority to monitor PBM contracting and reimbursement at the federal level, and states across the country have enacted or advanced their own comprehensive PBM reform measures.
For Massachusetts community pharmacies, HB 4493 addresses the structural challenges that have eroded profitability and threatened their ability to serve patients. The Medicaid-floor reimbursement standard, prohibition of retroactive clawbacks, anti-steering protections, and specialty pharmacy access requirements collectively represent meaningful structural relief for pharmacies that have been forced to operate at unsustainable margins. We encourage pharmacies to reach out to their legislators to urge passage of HB 4493.
How Frier Levitt Can Help
Frier Levitt has spent more than two decades representing independent pharmacies nationwide in PBM audits, reimbursement disputes, network access challenges, and regulatory compliance matters. Our team has helped pharmacies recover millions in withheld reimbursements, reversed network terminations, and challenged PBM practices that overstep legal boundaries.
We routinely represent pharmacies seeking to leverage state PBM laws during audits, network terminations, and credentialing processes and collaborate with pharmacy associations nationwide to help draft and support protective legislation.
If your pharmacy has questions about how Massachusetts HB 4493 may affect your operations, reimbursement, or PBM relationships, contact Frier Levitt today to speak with an experienced pharmacy law attorney.
Senior Associate
