The recently enacted prescription drug reform law in Massachusetts aims to reduce out-of-pocket costs for individuals with diabetes, asthma, and certain heart conditions. However, gaps in coverage remain for many residents enrolled in self-insured health plans, prompting discussions about potential future expansions.

During a Health Policy Commission (HPC) board meeting, Executive Director David Seltz outlined the law’s scope, which limits copays for select medications to $25 for those enrolled in MassHealth, the Group Insurance Commission, and fully insured commercial health plans. While these provisions represent a significant step forward in addressing drug affordability, they exclude residents covered by self-insured plans.

Self-insured plans, typically offered by larger employers, allow companies to collect premiums and directly cover medical expenses for their employees. These plans are not subject to state mandates, as federal law restricts state governments from imposing requirements on them.

“It’s a limitation we face,” said Sen. Cindy Friedman, one of the bill’s architects. She noted that this exclusion, rooted in federal law, leaves a significant number of individuals without the law’s cost-saving protections.

HPC Commissioner David Cutler estimated that about half of privately insured Massachusetts residents might fall under self-insured plans, further highlighting the scope of the gap. “This is not a trivial matter,” Cutler said. “Almost all large employers use self-insured models, and some smaller companies do as well.”

Seltz emphasized that while self-insured plans are not legally bound to adopt these copay caps, some may choose to incorporate them voluntarily. The HPC plans to evaluate the law’s impact every two years, analyzing how it benefits patients and whether it drives cost savings in the healthcare system.

“This is an opportunity for us to examine the broader implications,” Seltz said. “We can explore whether demonstrating economic and health benefits could make a case for broader application.”

HPC Commissioner Alecia McGregor underscored the importance of ensuring that more residents benefit from the law’s provisions. The current exclusion of self-insured plans, she argued, represents a significant challenge to achieving equitable healthcare access across the state.

As the HPC continues its analysis, regulators may propose policy changes to encourage wider adoption of cost-control measures. While the law is a critical step forward, its limitations point to the need for ongoing advocacy and potential federal reforms to ensure that all Bay Staters, regardless of their insurance type, can access affordable medications.

The path forward will depend on the data collected over the coming years and the willingness of policymakers and stakeholders to address the disparities in coverage. For now, the prescription drug reform law serves as a partial but important solution, with significant work ahead to close the gaps and expand access to affordable healthcare for all Massachusetts residents.