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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
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An act relating to pharmacies and pharmacy benefit 2
managers; transferring, renumbering, and amending s. 3
465.1885, F.S.; revising the entities conducting 4
pharmacy audits to which certain requirements and 5
restrictions apply; authorizing audited pharmacies to 6
appeal certain findings; providing that health 7
insurers and health maintenance organizations that 8
transfer certain payment obligation to pharmacy 9
benefit managers remain responsible for specified 10
violations; amending s. 624.490, F.S.; providing a 11
penalty for failure to register as pharmacy benefit 12
managers under certain circumstances; providing an 13
effective date. 14
15
Be It Enacted by the Legislature of t he State of Florida: 16
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Section 1. Section 465.1885, Florida Statutes, is 18
transferred, renumbered as section 624.491, Florida Statutes, 19
and amended to read: 20
624.491 465.1885 Pharmacy audits; rights.— 21
(1) A health insurer or health maintenance organiz ation 22
providing pharmacy benefits through a major medical individual 23
or group health insurance policy or a health maintenance 24
contract, respectively, must comply with the requirements of 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
this section when the health insurer or health maintenance 26
organization or any person or entity acting on behalf of the 27
health insurer or health maintenance organization, including, 28
but not limited to, a pharmacy benefit manager as defined in s. 29
624.490(1), audits the records of a pharmacy licensed under 30
chapter 465. The person or entity conducting such audit must If 31
an audit of the records of a pharmacy licensed under this 32
chapter is conducted directly or indirectly by a managed care 33
company, an insurance company, a third -party payor, a pharmacy 34
benefit manager, or an entit y that represents responsible 35
parties such as companies or groups, referred to as an "entity" 36
in this section, the pharmacy has the following rights : 37
(a) Except as provided in subsection (3), notify the 38
pharmacy To be notified at least 7 calendar days be fore the 39
initial onsite audit for each audit cycle. 40
(b) Not schedule an To have the onsite audit during 41
scheduled after the first 3 calendar days of a month unless the 42
pharmacist consents otherwise. 43
(c) Limit the duration of To have the audit period limited 44
to 24 months after the date a claim is submitted to or 45
adjudicated by the entity. 46
(d) In the case of To have an audit that requires clinical 47
or professional judgment , conduct the audit in consultation 48
with, or allow the audit to be conducted by, or in consultation 49
with a pharmacist. 50
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(e) Allow the pharmacy to use the written and verifiable 51
records of a hospital, physician, or other authorized 52
practitioner, which are transmitted by any means of 53
communication, to validate the pharmacy records in acco rdance 54
with state and federal law. 55
(f) Reimburse the pharmacy To be reimbursed for a claim 56
that was retroactively denied for a clerical error, 57
typographical error, scrivener's error, or computer error if the 58
prescription was properly and correctly dispen sed, unless a 59
pattern of such errors exists, fraudulent billing is alleged, or 60
the error results in actual financial loss to the entity. 61
(g) Provide the pharmacy with a copy of To receive the 62
preliminary audit report within 120 days after the conclusion of 63
the audit. 64
(h) Allow the pharmacy to produce documentation to address 65
a discrepancy or audit finding within 10 business days after the 66
preliminary audit report is delivered to the pharmacy. 67
(i) Provide the pharmacy with a copy of To receive the 68
final audit report within 6 months after the pharmacy's receipt 69
of receiving the preliminary audit report. 70
(j) Calculate any To have recoupment or penalties based on 71
actual overpayments and not according to the accounting practice 72
of extrapolation. 73
(2) The rights contained in This section does do not apply 74
to: 75
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(a) Audits in which suspected fraudulent activity or other 76
intentional or willful misrepresentation is evidenced by a 77
physical review, review of claims data or statements, or other 78
investigative methods; 79
(b) Audits of claims paid for by federally funded 80
programs; or 81
(c) Concurrent reviews or desk audits that occur within 3 82
business days after of transmission of a claim and where no 83
chargeback or recoupment is demanded. 84
(3) An entity that audits a pharmacy located within a 85
Health Care Fraud Prevention and Enforcement Action Team (HEAT) 86
Task Force area designated by the United States Department of 87
Health and Human Services and the United States Department of 88
Justice may dispense with the notice re quirements of paragraph 89
(1)(a) if such pharmacy has been a member of a credentialed 90
provider network for less than 12 months. 91
(4) Pursuant to s. 408.7057, and after receipt of the 92
final audit report issued under paragraph (1)(i), a pharmacy may 93
appeal the findings of the final audit report as to whether a 94
claim payment is due and as to the amount of a claim payment. 95
(5) A health insurer or health maintenance organization 96
that, under terms of a contract, transfers to a pharmacy benefit 97
manager the obligation to pay a pharmacy licensed under chapter 98
465 for any pharmacy benefit claims arising from services 99
provided to or for the benefit of an insured or subscriber 100
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remains responsible for a violation of this section. 101
Section 2. Subsection (6) of section 624.490, Florida 102
Statutes, is renumbered as subsection (7), and a new subsection 103
(6) is added to that section, to read: 104
624.490 Registration of pharmacy benefit managers. — 105
(6) A person who fails to register with th e office while 106
operating as a pharmacy benefit manager is subject to a fine of 107
$10,000 for each violation. 108
Section 3. This act shall take effect July 1, 2022. 109