Read the full stored bill text
Florida Senate
-
2026
SB 1166
By
Senator Rodriguez
40-00510-26 20261166__
1 A bill to be entitled
2 An act relating to insurer disclosures on prescription
3 drug coverage; creating s. 627.42394, F.S.; requiring
4 individual and group health insurers to provide notice
5 of prescription drug formulary changes within a
6 certain timeframe to current and prospective insureds
7 and the insureds’ treating physicians; specifying
8 requirements for the content of such notice and the
9 manner in which it must be provided; specifying
10 requirements for a notice of medical necessity
11 submitted by the treating physician; authorizing
12 insurers to provide certain means for submitting the
13 notice of medical necessity; requiring the Financial
14 Services Commission to adopt a certain form by rule by
15 a specified date; specifying a coverage requirement
16 and restrictions on coverage modification by insurers
17 receiving a notice of medical necessity; providing
18 construction and applicability; requiring insurers to
19 maintain a record of formulary changes; requiring
20 insurers to annually submit a specified report to the
21 Office of Insurance Regulation by a specified date;
22 requiring the office to annually compile certain data
23 and prepare a report, make the report publicly
24 accessible on its website, and submit the report to
25 the Governor and the Legislature by a specified date;
26 creating s. 627.6383, F.S.; defining the term “cost
27 sharing requirement”; requiring specified individual
28 health insurers and their pharmacy benefit managers to
29 apply payments for prescription drugs by or on behalf
30 of insureds toward the insureds’ total contributions
31 to cost-sharing requirements under certain
32 circumstances; providing construction; requiring
33 specified individual health insurers to maintain
34 records of certain third-party payments for
35 prescription drugs; providing reporting requirements
36 relating to third-party payments for prescription
37 drugs; providing requirements for the reports;
38 providing applicability; amending s. 627.6385, F.S.;
39 providing disclosure requirements relating to a
40 policyholder’s total cost-sharing requirement for
41 prescription drugs; providing applicability; amending
42 s. 627.64741, F.S.; requiring that specified contracts
43 require pharmacy benefit managers to apply payments by
44 or on behalf of insureds toward the insureds’ total
45 contributions to cost-sharing requirements; providing
46 applicability; providing disclosure requirements
47 relating to a policyholder’s total cost-sharing
48 requirement for prescription drugs; creating s.
49 627.65715, F.S.; defining the term “cost-sharing
50 requirement”; requiring specified group health
51 insurers and their pharmacy benefit managers to apply
52 payments for prescription drugs by or on behalf of
53 insureds toward the insureds’ total contributions to
54 cost-sharing requirements under certain circumstances;
55 providing construction; providing disclosure
56 requirements relating to an insured person’s total
57 cost-sharing requirement for prescription drugs;
58 requiring specified group health insurers to maintain
59 records of certain third-party payments for
60 prescription drugs; providing reporting requirements;
61 providing requirements for the reports; providing
62 applicability; amending s. 627.6572, F.S.; requiring
63 that specified contracts require pharmacy benefit
64 managers to apply payments by or on behalf of insureds
65 toward the insureds’ total contributions to cost
66 sharing requirements; providing applicability;
67 providing disclosure requirements; amending s.
68 627.6699, F.S.; requiring small employer carriers to
69 comply with certain requirements for prescription drug
70 formulary changes; amending s. 641.31, F.S.; providing
71 an exception to requirements relating to changes in a
72 health maintenance organization’s group contract;
73 requiring health maintenance organizations to provide
74 notice of prescription drug formulary changes within a
75 certain timeframe to current and prospective
76 subscribers and the subscribers’ treating physicians;
77 specifying requirements for the content of such notice
78 and the manner in which it must be provided;
79 specifying requirements for a notice of medical
80 necessity submitted by the treating physician;
81 authorizing health maintenance organizations to
82 provide certain means for submitting the notice of
83 medical necessity; requiring the commission to adopt a
84 certain form by rule by a specified date; specifying a
85 coverage requirement and restrictions on coverage
86 modification by health maintenance organizations
87 receiving a notice of medical necessity; providing
88 construction and applicability; requiring health
89 maintenance organizations to maintain a record of
90 formulary changes; requiring health maintenance
91 organizations to annually submit a specified report to
92 the office by a specified date; requiring the office
93 to annually compile certain data and prepare a report,
94 make the report publicly accessible on its website,
95 and submit the report to the Governor and the
96 Legislature by a specified date; defining the term
97 “cost-sharing requirement”; requiring specified health
98 maintenance organizations and their pharmacy benefit
99 managers to apply payments for prescription drugs by
100 or on behalf of subscribers toward the subscribers’
101 total contributions to cost-sharing requirements under
102 certain circumstances; providing construction;
103 providing disclosure requirements relating to the
104 subscriber’s total contributions to cost-sharing
105 requirements; requiring specified health maintenance
106 organizations to maintain records of certain third
107 party payments for prescription drugs; providing
108 reporting requirements; providing requirements for the
109 reports; providing applicability; amending s. 641.314,
110 F.S.; requiring that specified contracts require
111 pharmacy benefit managers to apply payments by or on
112 behalf of subscribers toward the subscribers’ total
113 contributions to cost-sharing requirements; providing
114 applicability; providing disclosure requirements
115 relating to a subscriber’s total cost-sharing
116 requirement for prescription drugs; amending s.
117 409.967, F.S.; conforming a cross-reference; amending
118 s. 641.185, F.S.; conforming a provision to changes
119 made by the act; providing applicability; providing a
120 declaration of important state interest; providing an
121 effective date.
122
123 Be It Enacted by the Legislature of the State of Florida:
124
125 Section 1. Section 627.42394, Florida Statutes, is created
126 to read:
127
627.42394
Health insurance policies; changes to
128
prescription drug formularies; requirements.—
129
(1)
At least 60 days before the effective date of any
130
change to a prescription drug formulary during a policy year, an
131
insurer issuing individual or group health insurance policies in
132
this state shall notify:
133
(a)
Current and prospective insureds of the change in the
134
formulary, in a readily accessible format on the insurer’s
135
website; and
136
(b)
Any insured currently receiving coverage for a
137
prescription drug for whom the formulary change modifies
138
coverage and the insured’s treating physician. Such notification
139
must be sent electronically and by first-class mail and must
140
include information on the specific drugs involved and a
141
statement that the submission of a notice of medical necessity
142
by the insured’s treating physician to the insurer at least 30
143
days before the effective date of the formulary change will
144
result in continuation of coverage at the existing level.
145
(2)
The notice of medical necessity provided by the
146
treating physician to the insurer must include a completed one
147
page form in which the treating physician certifies to the
148
insurer that the prescription drug for the insured is medically
149
necessary as defined in s. 627.732(2). The treating physician
150
shall submit the notice electronically or by first-class mail.
151
The insurer may provide the treating physician with access to an
152
electronic portal through which the treating physician may
153
electronically submit the notice. By January 1, 2027, the
154
commission shall adopt by rule a form for the notice.
155
(3)
If the treating physician certifies to the insurer in
156
accordance with subsection (2) that the prescription drug is
157
medically necessary for the insured, the insurer:
158
(a)
Must authorize coverage for the prescribed drug until
159
the end of the policy year, based solely on the treating
160
physician’s certification that the drug is medically necessary;
161
and
162
(b)
May not modify the coverage related to the covered drug
163
during the policy year by:
164
1.
Increasing the out-of-pocket costs for the covered drug;
165
2.
Moving the covered drug to a more restrictive tier;
166
3.
Denying an insured coverage of the drug for which the
167
insured has been previously approved for coverage by the
168
insurer; or
169
4.
Limiting or reducing coverage of the drug in any other
170
way, including subjecting it to a new prior authorization or
171
step-therapy requirement.
172
(4)
Subsections (1), (2), and (3) do not:
173
(a)
Prohibit the addition of prescription drugs to the list
174
of drugs covered under the policy during the policy year.
175
(b)
Apply to a grandfathered health plan as defined in s.
176
627.402 or to benefits specified in s. 627.6513.
177
(c)
Alter or amend s. 465.025, which provides conditions
178
under which a pharmacist may substitute a generically equivalent
179
drug product for a brand name drug product.
180
(d)
Alter or amend s. 465.0252, which provides conditions
181
under which a pharmacist may dispense a substitute biological
182
product for the prescribed biological product.
183
(e)
Apply to a Medicaid managed care plan under part IV of
184
chapter 409.
185
(5)
A health insurer shall maintain a record of any change
186
in its formulary during a calendar year. By March 1 of each
187
year, a health insurer shall submit to the office a report
188
delineating such changes made in the previous calendar year. The
189
annual report must include all of the following, at a minimum:
190
(a)
A list of all drugs removed from the formulary, along
191
with the date of the removal and the reasons for the removal.
192
(b)
A list of all drugs moved to a tier resulting in
193
additional out-of-pocket costs to insureds.
194
(c)
The number of insureds impacted by a change in the
195
formulary.
196
(d)
The number of insureds notified by the insurer of a
197
change in the formulary.
198
(e)
The increased cost, by dollar amount, incurred by
199
insureds because of such change in the formulary.
200
(6)
By May 1 of each year, the office shall:
201
(a)
Compile the data in the annual reports submitted by
202
health insurers under subsection (5) and prepare a report
203
summarizing such data.
204
(b)
Make the report publicly accessible on its website.
205
(c)
Submit the report to the Governor, the President of the
206
Senate, and the Speaker of the House of Representatives.
207 Section 2. Section 627.6383, Florida Statutes, is created
208 to read:
209
627.6383
Cost-sharing requirements.—
210
(1)
As used in this section, the term “cost-sharing
211
requirement” means a dollar limit, a deductible, a copayment,
212
coinsurance, or any other out-of-pocket expense imposed on an
213
insured, including, but not limited to, the annual limitation on
214
cost sharing subject to 42 U.S.C. s. 18022.
215
(2)(a)
Each health insurer issuing, delivering, or renewing
216
a policy in this state which provides prescription drug
217
coverage, or each pharmacy benefit manager on behalf of such
218
health insurer, shall apply any amount paid for a prescription
219
drug by an insured or by another person on behalf of the insured
220
toward the insured’s total contribution to any cost-sharing
221
requirement, if the prescription drug:
222
1.
Does not have a generic equivalent; or
223
2.
Has a generic equivalent and the insured has obtained
224
authorization for the prescription drug through any of the
225
following:
226
a.
Prior authorization from the health insurer or pharmacy
227
benefit manager.
228
b.
A step-therapy protocol.
229
c.
The exception or appeal process of the health insurer or
230
pharmacy benefit manager.
231
(b)
The amount paid by or on behalf of the insured which is
232
applied toward the insured’s total contribution to any cost
233
sharing requirement under paragraph (a) includes, but is not
234
limited to, any payment with or any discount through financial
235
assistance, a manufacturer copay card, a product voucher, or any
236
other reduction in out-of-pocket expenses made by or on behalf
237
of the insured for a prescription drug.
238
(c)1.
Each health insurer issuing, delivering, or renewing
239
a policy in this state which provides prescription drug
240
coverage, regardless of whether the prescription drug benefits
241
are administered or managed by the insurer or by a pharmacy
242
benefit manager on behalf of the insurer, shall maintain a
243
record of any third-party payments made or remitted on behalf of
244
an insured for prescription drugs, which payments are not
245
applied to the insured’s out-of-pocket obligations, including,
246
but not limited to, deductibles, copayments, or coinsurance.
247
2.
By March 1 of each year, each health insurer issuing,
248
delivering, or renewing a policy in this state which provides
249
prescription drug coverage, regardless of whether the
250
prescription drug benefits are administered or managed by the
251
insurer or by a pharmacy benefit manager on behalf of the
252
insurer, shall submit to the office a report delineating third
253
party payments, as described in subparagraph 1., which were
254
received in the previous calendar year. The annual report must
255
include, at a minimum:
256
a.
A list of all payments received by the health insurer,
257
as described in subparagraph 1., made or remitted by a third
258
party, which must include all of the following:
259
(I)
The date each payment was made.
260
(II)
The prescription drug for which the payment was made.
261
(III)
The reason that the payment was not applied to the
262
insured’s out-of-pocket obligations.
263
b.
The total amount of payments received by the health
264
insurer which were not applied to an insured’s out-of-pocket
265
maximum.
266
c.
The total number of insureds for whom a payment was made
267
which was not applied to an out-of-pocket maximum.
268
d.
Whether such payments were returned to the third party
269
that submitted the payment.
270
e.
The total amount of payments which were not returned to
271
the third party that submitted the payment.
272
(3)
This section applies to any health insurance policy
273
issued, delivered, or renewed in this state on or after January
274
1, 2027.
275 Section 3. Present subsections (2) and (3) of section
276 627.6385, Florida Statutes, are redesignated as subsections (3)
277 and (4), respectively, a new subsection (2) is added to that
278 section, and present subsection (2) of that section is amended,
279 to read:
280 627.6385 Disclosures to policyholders; calculations of cost
281 sharing.—
282
(2)
Each health insurer issuing, delivering, or renewing a
283
policy in this state which provides prescription drug coverage,
284
regardless of whether the prescription drug benefits are
285
administered or managed by the health insurer or by a pharmacy
286
benefit manager on behalf of the health insurer, shall disclose
287
on its website that any amount paid by a policyholder or by
288
another person on behalf of the policyholder must be applied
289
toward the policyholder’s total contribution to any cost-sharing
290
requirement pursuant to s. 627.6383. This subsection applies to
291
any policy issued, delivered, or renewed in this state on or
292
after January 1, 2027.
293
(3)
(2)
Each health insurer shall include in every policy
294 delivered or issued for delivery to any person in
this
the
state
295 or in materials provided as required by s. 627.64725
a
notice
296 that the information required by this section is available
297 electronically and the
website
address
of the website
where the
298 information can be accessed.
In addition, each health insurer
299
issuing, delivering, or renewing a policy in this state which
300
provides prescription drug coverage, regardless of whether the
301
prescription drug benefits are administered or managed by the
302
health insurer or by a pharmacy benefit manager on behalf of the
303
health insurer, shall disclose in every policy that is issued,
304
delivered, or renewed to any person in this state on or after
305
January 1, 2027, that any amount paid by a policyholder or by
306
another person on behalf of the policyholder must be applied
307
toward the policyholder’s total contribution to any cost-sharing
308
requirement pursuant to s. 627.6383.
309 Section 4. Paragraph (c) is added to subsection (2) of
310 section 627.64741, Florida Statutes, to read:
311 627.64741 Pharmacy benefit manager contracts.—
312 (2) In addition to the requirements of part VII of chapter
313 626, a contract between a health insurer and a pharmacy benefit
314 manager must require that the pharmacy benefit manager:
315
(c)1.
Apply any amount paid by an insured or by another
316
person on behalf of the insured toward the insured’s total
317
contribution to any cost-sharing requirement pursuant to s.
318
627.6383. This subparagraph applies to any insured whose
319
insurance policy is issued, delivered, or renewed in this state
320
on or after January 1, 2027.
321
2.
Disclose to every insured whose insurance policy is
322
issued, delivered, or renewed in this state on or after January
323
1, 2027, that the pharmacy benefit
manager is required to app
ly
324
any amount paid by the insured or by another person on behalf of
325
the insured toward the insured’s total contribution to any cost
326
sharing requirement pursuant to s. 627.6383.
327 Section 5. Section 627.65715, Florida Statutes, is created
328 to read:
329
627.65715
Cost-sharing requirements.—
330
(1)
As used in this section, the term “cost-sharing
331
requirement” means a dollar limit, a deductible, a copayment,
332
coinsurance, or any other out-of-pocket expense imposed on an
333
insured, including, but not limited to, the annual limitation on
334
cost sharing subject to 42 U.S.C. s. 18022.
335
(2)(a)
Each insurer issuing, delivering, or renewing a
336
policy in this state which provides prescription drug coverage,
337
or each pharmacy benefit manager on behalf of such insurer,
338
shall apply any amount paid for a prescription drug by an
339
insured or by another person on behalf of the insured toward the
340
insured’s total contribution to any cost-sharing requirement, if
341
the prescription drug:
342
1.
Does not have a generic equivalent; or
343
2.
Has a generic equivalent and the insured has obtained
344
authorization for the prescription drug through any of the
345
following:
346
a.
Prior authorization from the insurer or pharmacy benefit
347
manager.
348
b.
A step-therapy protocol.
349
c.
The exception or appeal process of the insurer or
350
pharmacy benefit manager.
351
(b)
The amount paid by or on behalf of the insured which is
352
applied toward the insured’s total contribution to any cost
353
sharing requirement under paragraph (a) includes, but is not
354
limited to, any payment with or any discount through financial
355
assistance, a manufacturer copay card, a product voucher, or any
356
other reduction in out-of-pocket expenses made by or on behalf
357
of the insured for a prescription drug.
358
(3)(a)
Each insurer issuing, delivering, or renewing a
359
policy in this state which provides prescription drug coverage,
360
regardless of whether the prescription drug benefits are
361
administered or managed by the insurer or by a pharmacy benefit
362
manager on behalf of the insurer, shall disclose on its website
363
and in every policy issued, delivered, or renewed in this state
364
on or after January 1, 2027, that any amount paid by an insured
365
or by another person on behalf of the insured must be applied
366
toward the insured’s total contribution to any cost-sharing
367
requirement.
368
(b)1.
Each insurer issuing, delivering, or renewing a
369
policy in this state which provides prescription drug coverage,
370
regardless of whether the prescription drug benefits are
371
administered or managed by the insurer or by a pharmacy benefit
372
manager on behalf of the insurer, shall maintain a record of any
373
third-party payments made or remitted on behalf of an insured
374
for prescription drugs, which payments are not applied to the
375
insured’s out-of-pocket obligations, including, but not limited
376
to, deductibles, copayments, or coinsurance.
377
2.
By March 1 of each year, each health insurer issuing,
378
delivering, or renewing a policy in this state which provides
379
prescription drug coverage, regardless of whether the
380
prescription drug benefits are administered or managed by the
381
insurer or by a pharmacy benefit manager on behalf of the
382
insurer, shall submit to the office a report delineating third
383
party payments, as described in subparagraph 1., which were
384
received in the previous calendar year. The annual report must
385
include, at a minimum:
386
a.
A list of all payments received by the health insurer,
387
as described in subparagraph 1., made or remitted by a third
388
party, which must include:
389
(I)
The date each payment was made.
390
(II)
The prescription drug for which the payment was made.
391
(III)
The reason that the payment was not applied to the
392
insured’s out-of-pocket obligations.
393
b.
The total amount of payments received by the health
394
insurer which were not applied to an insured’s out-of-pocket
395
maximum.
396
c.
The total number of insureds for whom a payment was made
397
which was not applied to an out-of-pocket maximum.
398
d.
Whether such payments were returned to the third party
399
that submitted the payment.
400
e.
The total amount of payments which were not returned to
401
the third party that submitted the payment.
402
(4)
This section applies to any group health insurance
403
policy issued, delivered, or renewed in this state on or after
404
January 1, 2027.
405 Section 6. Paragraph (c) is added to subsection (2) of
406 section 627.6572, Florida Statutes, to read:
407 627.6572 Pharmacy benefit manager contracts.—
408 (2) In addition to the requirements of part VII of chapter
409 626, a contract between a health insurer and a pharmacy benefit
410 manager must require that the pharmacy benefit manager:
411
(c)1.
Apply any amount paid by an insured or by another
412
person on behalf of the insured toward the insured’s total
413
contribution to any cost-sharing requirement pursuant to s.
414
627.65715. This subparagraph applies to any insured whose
415
insurance policy is issued, delivered, or renewed in this state
416
on or after January 1, 2027.
417
2.
Disclose to every insured whose insurance policy is
418
issued, delivered, or renewed in this state on or after January
419
1, 2027, that the pharmacy benefit manager is required to apply
420
any amount paid by the insured or by another person on behalf of
421
the insured toward the insured’s total contribution to any cost
422
sharing requirement pursuant to s. 627.65715.
423 Section 7. Paragraph (e) of subsection (5) of section
424 627.6699, Florida Statutes, is amended to read:
425 627.6699 Employee Health Care Access Act.—
426 (5) AVAILABILITY OF COVERAGE.—
427 (e) All health benefit plans issued under this section must
428 comply with the following conditions:
429 1. For employers who have fewer than two employees, a late
430 enrollee may be excluded from coverage for no longer than 24
431 months if he or she was not covered by creditable coverage
432 continually to a date not more than 63 days before the effective
433 date of his or her new coverage.
434 2. Any requirement used by a small employer carrier in
435 determining whether to provide coverage to a small employer
436 group, including requirements for minimum participation of
437 eligible employees and minimum employer contributions, must be
438 applied uniformly among all small employer groups having the
439 same number of eligible employees applying for coverage or
440 receiving coverage from the small employer carrier, except that
441 a small employer carrier that participates in, administers, or
442 issues health benefits pursuant to s. 381.0406 which do not
443 include a preexisting condition exclusion may require as a
444 condition of offering such benefits that the employer has had no
445 health insurance coverage for its employees for a period of at
446 least 6 months. A small employer carrier may vary application of
447 minimum participation requirements and minimum employer
448 contribution requirements only by the size of the small employer
449 group.
450 3. In applying minimum participation requirements with
451 respect to a small employer, a small employer carrier
may
shall
452 not consider as an eligible employee employees or dependents who
453 have qualifying existing coverage in an employer-based group
454 insurance plan or an ERISA qualified self-insurance plan in
455 determining whether the applicable percentage of participation
456 is met. However, a small employer carrier may count eligible
457 employees and dependents who have coverage under another health
458 plan that is sponsored by that employer.
459 4. A small employer carrier
may
shall
not increase any
460 requirement for minimum employee participation or any
461 requirement for minimum employer contribution applicable to a
462 small employer at any time after the small employer has been
463 accepted for coverage, unless the employer size has changed, in
464 which case the small employer carrier may apply the requirements
465 that are applicable to the new group size.
466 5. If a small employer carrier offers coverage to a small
467 employer, it must offer coverage to all the small employer’s
468 eligible employees and their dependents. A small employer
469 carrier may not offer coverage limited to certain persons in a
470 group or to part of a group, except with respect to late
471 enrollees.
472 6. A small employer carrier may not modify any health
473 benefit plan issued to a small employer with respect to a small
474 employer or any eligible employee or dependent through riders,
475 endorsements, or otherwise to restrict or exclude coverage for
476 certain diseases or medical conditions otherwise covered by the
477 health benefit plan.
478 7. An initial enrollment period of at least 30 days must be
479 provided. An annual 30-day open enrollment period must be
480 offered to each small employer’s eligible employees and their
481 dependents. A small employer carrier must provide special
482 enrollment periods as required by s. 627.65615.
483
8.
A small employer carrier shall comply with s. 627.65715
484
for any change to a prescription drug formulary.
485 Section 8. Subsection (36) of section 641.31, Florida
486 Statutes, is amended, and subsection (48) is added to that
487 section, to read:
488 641.31 Health maintenance contracts.—
489 (36)
Except as provided in paragraphs (a), (b), and (c),
a
490 health maintenance organization may increase the copayment for
491 any benefit, or delete, amend, or limit any of the benefits to
492 which a subscriber is entitled under the group contract only,
493 upon written notice to the contract holder at least 45 days in
494 advance of the time of coverage renewal. The health maintenance
495 organization may amend the contract with the contract holder,
496 with such amendment to be effective immediately at the time of
497 coverage renewal. The written notice to the contract holder
must
498
shall
specifically identify any deletions, amendments, or
499 limitations to any of the benefits provided in the group
500 contract during the current contract period which will be
501 included in the group contract upon renewal. This subsection
502 does not apply to any increases in benefits. The 45-day notice
503 requirement
does
shall
not apply if benefits are amended,
504 deleted, or limited at the request of the contract holder.
505
(a)
At least 60 days before the effective date of any
506
change to a prescription drug formulary during a contract year,
507
a health maintenance organization shall notify:
508
1.
Current and prospective subscribers of the change in the
509
formulary, in a readily accessible format on the health
510
maintenance organization’s website; and
511
2.
Any subscriber currently receiving coverage for a
512
prescription drug for whom the formulary change modifies
513
coverage and the subscriber’s treating physician. Such
514
notification must be sent electronically and by first-class mail
515
and must include information on the specific drugs involved and
516
a statement that the submission of a notice of medical necessity
517
by the subscriber’s treating physician to the health maintenance
518
organization at least 30 days before the effective date of the
519
formulary change will result in continuation of coverage at the
520
existing level.
521
(b)
The notice of medical necessity provided by the
522
treating physician to the health maintenance organization must
523
include a completed one-page form in which the treating
524
physician certifies to the health maintenance organization that
525
the prescription drug for the subscriber is medically necessary
526
as defined in s. 627.732(2). The treating physician shall submit
527
the notice electronically or by first-class mail. The health
528
maintenance organization may provide the treating physician with
529
access to an electronic portal through which the treating
530
physician may electronically submit the notice. By January 1,
531
2027, the commission shall adopt by rule a form for the notice.
532
(c)
If the treating physician certifies to the health
533
maintenance organization in accordance with paragraph (b) that
534
the prescription drug is medically necessary for the subscriber,
535
the health maintenance organization:
536
1.
Must authorize coverage for the prescribed drug until
537
the end of the contract year, based solely on the treating
538
physician’s certification that the drug is medically necessary;
539
and
540
2.
May not modify the coverage related to the covered drug
541
during the contract year by:
542
a.
Increasing the out-of-pocket costs for the covered drug;
543
b.
Moving the covered drug to a more restrictive tier;
544
c.
Denying a subscriber coverage of the drug for which the
545
subscriber has been previously approved for coverage by the
546
health maintenance organization; or
547
d.
Limiting or reducing coverage of the drug in any other
548
way, including subjecting it to a new prior authorization or
549
step-therapy requirement.
550
(d)
Paragraphs (a), (b), and (c) do not:
551
1.
Prohibit the addition of prescription drugs to the list
552
of drugs covered under the contract during the contract year.
553
2.
Apply to a grandfathered health plan as defined in s.
554
627.402 or to benefits specified in s. 627.6513.
555
3.
Alter or amend s. 465.025, which provides conditions
556
under which a pharmacist may substitute a generically equivalent
557
drug product for a brand name drug product.
558
4.
Alter or amend s. 465.0252, which provides conditions
559
under which a pharmacist may dispense a substitute biological
560
product for the prescribed biological product.
561
5.
Apply to a Medicaid managed care plan under part IV of
562
chapter 409.
563
(e)
A health maintenance organization shall maintain a
564
record of any change in its formulary during a calendar year. By
565
March 1 of each year, a health maintenance organization shall
566
submit to the office a report delineating such changes made in
567
the previous calendar year. The annual report must include, at a
568
minimum:
569
1.
A list of all drugs removed from the formulary, along
570
with the date of the removal and the reasons for the removal.
571
2.
A list of all drugs moved to a tier resulting in
572
additional out-of-pocket costs to subscribers.
573
3.
The number of subscribers impacted by a change in the
574
formulary
.
575
4.
The number of subscribers notified by the health
576
maintenance organization of a change in the formulary.
577
5.
The increased cost, by dollar amount, incurred by
578
subscribers because of such change in the formulary.
579
(f)
By May 1 of each year, the office shall:
580
1.
Compile the data in the annual reports submitted by
581
health maintenance organizations under paragraph (e) and prepare
582
a report summarizing such data;
583
2.
Make the report publicly accessible on its website; and
584
3.
Submit the report to the Governor, the President of the
585
Senate, and the Speaker of the House of Representatives.
586
(48)(a)
As used in this subsection, the term “cost-sharing
587
requirement” means a dollar limit, a deductible, a copayment,
588
coinsurance, or any other out-of-pocket expense imposed on a
589
subscriber, including, but not limited to, the annual limitation
590
on cost sharing subject to 42 U.S.C. s. 18022.
591
(b)1.
Each health maintenance organization issuing,
592
delivering, or renewing a health maintenance contract or
593
certificate in this state which provides prescription drug
594
coverage, or each pharmacy benefit manager on behalf of such
595
health maintenance organization, shall apply any amount paid for
596
a prescription drug by a subscriber or by another person on
597
behalf of the subscriber toward the subscriber’s total
598
contribution to any cost-sharing requirement if the prescription
599
drug:
600
a.
Does not have a generic equivalent; or
601
b.
Has a generic equivalent and the subscriber has obtained
602
authorization for the prescription drug through any of the
603
following:
604
(I)
Prior authorization from the health maintenance
605
organization or pharmacy benefit manager.
606
(II)
A step-therapy protocol.
607
(III)
The exception or appeal process of the health
608
maintenance organization or pharmacy benefit manager.
609
2.
The amount paid by or on behalf of the subscriber which
610
is applied toward the subscriber’s total contribution to any
611
cost-sharing requirement under subparagraph 1. includes, but is
612
not limited to, any payment with or any discount through
613
financial assistance, a manufacturer copay card, a product
614
voucher, or any other reduction in out-of-pocket expenses made
615
by or on behalf of the subscriber for a prescription drug.
616
(c)
Each health maintenance organization issuing,
617
delivering, or renewing a health maintenance contract or
618
certificate in this state which provides prescription drug
619
coverage, regardless of whether the prescription drug benefits
620
are administered or managed by the health maintenance
621
organization or by a pharmacy benefit manager on behalf of the
622
health maintenance organization, shall disclose on its website
623
and in every subscriber’s health maintenance contract,
624
certificate, or member handbook issued, delivered, or renewed in
625
this state on or after January 1, 2027, that any amount paid by
626
a subscriber or by another person on behalf of the subscriber
627
must be applied toward the subscriber’s total contribution to
628
any cost-sharing requirement.
629
(d)1.
A health maintenance organization issuing,
630
delivering, or renewing a health maintenance contract or
631
certificate in this state which provides prescription drug
632
coverage, regardless of whether the prescription drug benefits
633
are administered or managed by the health maintenance
634
organization or by a pharmacy benefit manager on behalf of the
635
health maintenance organization, shall maintain a record of any
636
third-party payments made or remitted on behalf of a subscriber
637
for prescription drugs, which payments are not applied to the
638
subscriber’s out-of-pocket obligations, including, but not
639
limited to, deductibles, copayments, or coinsurance.
640
2.
By March 1 of each year, a health maintenance
641
organization shall submit to the office a report delineating
642
third-party payments, as described in subparagraph 1., which
643
were received in the previous calendar year. The annual report
644
must include, at a minimum:
645
a.
A list of all payments received by the health
646
maintenance organization, as described in subparagraph 1., made
647
or remitted by a third party, which must include:
648
(I)
The date each payment was made.
649
(II)
The prescription drug for which the payment was made.
650
(III)
The reason that the payment was not applied to the
651
subscriber’s out-of-pocket obligations.
652
b.
The total amount of payments received by the health
653
maintenance organization which were not applied to a
654
subscriber’s out-of-pocket maximum.
655
c.
The total number of subscribers for whom a payment was
656
made which was not applied to an out-of-pocket maximum.
657
d.
Whether such payments were returned to the third party
658
that submitted the payment.
659
e.
The total amount of payments which were not returned to
660
the third party that submitted the payment.
661
(e)
This subsection applies to any health maintenance
662
contract, certificate, or member handbook issued, delivered, or
663
renewed in this state on or after January 1, 2027.
664 Section 9. Paragraph (c) is added to subsection (2) of
665 section 641.314, Florida Statutes, to read:
666 641.314 Pharmacy benefit manager contracts.—
667 (2) In addition to the requirements of part VII of chapter
668 626, a contract between a health maintenance organization and a
669 pharmacy benefit manager must require that the pharmacy benefit
670 manager:
671
(c)1.
Apply any amount paid by a subscriber or by another
672
person on behalf of the subscriber toward the subscriber’s total
673
contribution to any cost-sharing requirement pursuant to s.
674
641.31(48). This subparagraph applies to any subscriber whose
675
health maintenance contract or certificate is issued, delivered,
676
or renewed in this state on or after January 1, 2027.
677
2.
Disclose to every subscriber whose health maintenance
678
contract or certificate is issued, delivered, or renewed in this
679
state on or after January 1, 2027, that the pharmacy benefit
680
manager is required to apply any amount paid by the subscriber
681
or by another person on behalf of the subscriber toward the
682
subscriber’s total contribution to any cost-sharing requirement
683
pursuant to s. 641.31(48).
684 Section 10. Paragraph (o) of subsection (2) of section
685 409.967, Florida Statutes, is amended to read:
686 409.967 Managed care plan accountability.—
687 (2) The agency shall establish such contract requirements
688 as are necessary for the operation of the statewide managed care
689 program. In addition to any other provisions the agency may deem
690 necessary, the contract must require:
691 (o)
Transparency.
—Managed care plans shall comply with
ss.
692
627.6385(4) and 641.54(7)
ss. 627.6385(3
)
and 641.54(7)
.
693 Section 11. Paragraph (k) of subsection (1) of section
694 641.185, Florida Statutes, is amended to read:
695 641.185 Health maintenance organization subscriber
696 protections.—
697 (1) With respect to the provisions of this part and part
698 III, the principles expressed in the following statements serve
699 as standards to be followed by the commission, the office, the
700 department, and the Agency for Health Care Administration in
701 exercising their powers and duties, in exercising administrative
702 discretion, in administrative interpretations of the law, in
703 enforcing its provisions, and in adopting rules:
704 (k) A health maintenance organization subscriber shall be
705 given a copy of the applicable health maintenance contract,
706 certificate, or member handbook specifying: all the provisions,
707 disclosure, and limitations required pursuant to s. 641.31(1)
,
708
and
(4)
, and (48)
; the covered services, including those
709 services, medical conditions, and provider types specified in
710 ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and
711 641.513; and where and in what manner services may be obtained
712 pursuant to s. 641.31(4).
713 Section 12.
This act applies to health insurance policies,
714
health benefit plans, and health maintenance contracts entered
715
into or renewed on or after January 1, 2027.
716 Section 13.
The Legislature finds that this act fulfills an
717
important state interest.
718 Section 14. This act shall take effect July 1, 2026.