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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
1
An act relating to drug prices and coverage; amending 2
s. 626.8825, F.S.; revising the definition of the term 3
"pharmacy benefits plan or program" to exclude a plan 4
or program that exclusively serves a PACE 5
organization; requiring contracts between pharmacy 6
benefit managers and participating pharmacies to allow 7
a specified option in the administrative appeal 8
procedure; amending s. 626.8827, F.S.; providing 9
pharmacy benefit manager prohibited practices relating 10
to pharmacies and pharmacists; providing an 11
appropriation for implementation of the Ryan White 12
Part B AIDS Drug Assistance Program (ADAP) through a 13
specified date; defining the term "low income" for 14
purposes of ADAP eligibility through a specified date; 15
providing requirements for the implementation of ADAP 16
through a specified date; requiring the Department of 17
Health to submit monthly reports providing a detailed 18
accounting of ADAP to the Governor's Office of Policy 19
and Budget and the chairs of the legislative 20
appropriations committees; specifying requirements for 21
the reports; requiring the department to adopt 22
emergency rules to implement ADAP; providing that such 23
emergency rules are exempt from specified rulemaking 24
requirements and remain in effect through a specified 25
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
date; providing effective dates. 26
27
Be It Enacted by the Legislature of the State of Florida: 28
29
Section 1. Paragraph (u) of subsection (1) and paragraph 30
(h) of subsection (3) of section 626.8825, Florida Statutes, are 31
amended to read: 32
626.8825 Pharmacy benefit manager transparency and 33
accountability.— 34
(1) DEFINITIONS.—As used in this section, the term: 35
(u) "Pharmacy benefits plan or program" means a plan or 36
program that pays for, reimburses, covers the cost of, or 37
provides access to discounts on pharmacist services provided by 38
one or more pharmacies to covered persons who reside in, are 39
employed by, or receive pharmacist services from this state. 40
1. The term includes, but is not limited to, health 41
maintenance organizations, health insurers, self-insured 42
employer health plans, discount card programs, and government-43
funded health plans, including the Statewide Medicaid Managed 44
Care program established pursuant to part IV of chapter 409 and 45
the state group insurance program pursuant to part I of chapter 46
110. 47
2. The term excludes such a plan or program under chapter 48
440 or a plan or program that exclusively serves a PACE 49
organization, as defined in s. 430.84(1). 50
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
(3) CONTRACTS BETWEEN A PHARMACY BENEFIT MANAGER AND A 51
PARTICIPATING PHARMACY.—In addition to other requirements in the 52
Florida Insurance Code, a participation contract executed, 53
amended, adjusted, or renewed on or after July 1, 2023, that 54
applies to pharmacist services on or after January 1, 2024, 55
between a pharmacy benefit manager and one or more pharmacies or 56
pharmacists, must include, in substantial form, terms that 57
ensure compliance with all of the following requirements, and 58
that, except to the extent not allowed by law, shall supersede 59
any contractual terms in the participation contract to the 60
contrary: 61
(h) The pharmacy benefit manager shall provide a 62
reasonable administrative appeal procedure to allow a pharmacy 63
or pharmacist to challenge the maximum allowable cost pricing 64
information and the reimbursement made under the maximum 65
allowable cost as defined in s. 627.64741 for a specific drug as 66
being below the acquisition cost available to the challenging 67
pharmacy or pharmacist. 68
1. The administrative appeal procedure must include a 69
telephone number and e-mail address, or a website, for the 70
purpose of submitting the administrative appeal. The appeal may 71
be submitted by the pharmacy or an agent of the pharmacy 72
directly to the pharmacy benefit manager or through a pharmacy 73
service administration organization. The administrative appeal 74
procedure must allow a pharmacy or pharmacist the option to 75
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
submit a consolidated administrative appeal representing 76
multiple adjudicated claims that share the same drug and day 77
supply and have a date of service occurring within the same 78
calendar month. The pharmacy or pharmacist must be given at 79
least 30 business days after a maximum allowable cost update or 80
after an adjudication for an electronic claim or reimbursement 81
for a nonelectronic claim to file the administrative appeal. 82
2. The pharmacy benefit manager must respond to the 83
administrative appeal within 30 business days after receipt of 84
the appeal. 85
3. If the appeal is upheld, the pharmacy benefit manager 86
must: 87
a. Update the maximum allowable cost pricing information 88
to at least the acquisition cost available to the pharmacy; 89
b. Permit the pharmacy or pharmacist to reverse and rebill 90
the claim in question; 91
c. Provide to the pharmacy or pharmacist the national drug 92
code on which the increase or change is based; and 93
d. Make the increase or change effective for each 94
similarly situated pharmacy or pharmacist who is subject to the 95
applicable maximum allowable cost pricing information. 96
4. If the appeal is denied, the pharmacy benefit manager 97
must provide to the pharmacy or pharmacist the national drug 98
code and the name of the national or regional pharmaceutical 99
wholesalers operating in this state which have the drug 100
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
currently in stock at a price below the maximum allowable cost 101
pricing information. 102
5. Every 90 days, a pharmacy benefit manager shall report 103
to the office the total number of appeals received and denied in 104
the preceding 90-day period, with an explanation or reason for 105
each denial, for each specific drug for which an appeal was 106
submitted pursuant to this paragraph. 107
Section 2. Subsections (8) and (9) are added to section 108
626.8827, Florida Statutes, to read: 109
626.8827 Pharmacy benefit manager prohibited practices.—In 110
addition to other prohibitions in this part, a pharmacy benefit 111
manager may not do any of the following: 112
(8) Prohibit or restrict a pharmacy or pharmacist from 113
declining to dispense a drug if the reimbursement rate is less 114
than the actual acquisition cost incurred or would be incurred 115
by the pharmacy or pharmacist. 116
(9) Reimburse a pharmacy or pharmacist less than it 117
reimburses an affiliated pharmacy or pharmacist, as those terms 118
are defined in s. 626.8825(1). 119
Section 3. For the 2025-2026 fiscal year, the nonrecurring 120
sum of $30,901,933 from the Grants and Donations Trust Fund is 121
appropriated to the Department of Health for implementation of 122
the Ryan White Part B AIDS Drug Assistance Program (ADAP) 123
through June 30, 2026. 124
(1) For purposes of ADAP eligibility through June 30, 125
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
2026, the term "low income" means an adjusted gross household 126
income at or below 400 percent of the federal poverty level. 127
(2) Through June 30, 2026, ADAP services may not be 128
provided through or by the purchase of health insurance that 129
includes coverage for HIV/AIDS medications but must be provided 130
through the distribution of medications directly to eligible 131
individuals. The HIV/AIDS medications directly dispensed under 132
ADAP must include all medications listed on the Florida AIDS 133
Drug Assistance Program (ADAP) Formulary as that formulary 134
existed on March 1, 2026. The Department of Health shall 135
distribute such medications to low income individuals who have 136
met the department's eligibility requirements. The department 137
shall ensure the availability of a clinically appropriate 138
medication for individuals with a creatinine clearance of less 139
than 60 milliliters per minute and may, as necessary to 140
implement this section within appropriated funds, provide such 141
medications only to those individuals. 142
(3) The Florida AIDS Drug Assistance Program (ADAP) Self-143
Insured Formulary as that formulary existed on March 1, 2026, 144
shall remain in effect through at least June 30, 2026. 145
(4) Beginning April 1, 2026, the Department of Health 146
shall submit monthly reports providing a detailed accounting of 147
ADAP to the Governor's Office of Policy and Budget, the chair of 148
the Senate Committee on Appropriations, and the chair of the 149
House of Representatives Budget Committee. 150
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
(a) The reports must include, at a minimum, all of the 151
following: 152
1. All state and federal revenues and expenditures; 153
2. All manufacturer rebates and other pharmaceutical 154
offsets received or accrued; 155
3. The total number of individuals participating in the 156
program; 157
4. Participant counts by county of residence or 158
administering organization, as applicable; 159
5. Participants' insurance statuses; 160
6. The number and type of prescriptions filled, including 161
utilization by drug class; and 162
7. Any other information necessary to provide transparency 163
with regard to program operations, utilization trends, cost 164
drivers, and fiscal sustainability. 165
(b) The department shall also include in its reports 166
month-over-month and year-to-date trend analyses and identify 167
any projected funding shortfalls, enrollment pressures, or 168
operational risks anticipated within the current fiscal year. 169
(c) Reports must be submitted in a consistent format to 170
allow comparison across reporting periods. 171
(5) The Department of Health shall adopt emergency rules 172
to implement ADAP in accordance with this section. Emergency 173
rules adopted under this section are exempt from s. 174
120.54(4)(c), Florida Statutes, and shall remain in effect 175
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
through June 30, 2026. 176
177
This section shall take effect upon this act becoming a law. 178
Section 4. Except as otherwise expressly provided in this 179
act and except for this section, which shall take effect upon 180
this act becoming a law, this act shall take effect July 1, 181
2026. 182