Florida 2022 Regular Session

Florida House Bill H0459 Compare Versions

Version 1 (Old)

Version 2 (New)

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10	10		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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	14	+	A bill to be entitled 1
15	15		An act relating to step -therapy protocols; amending s. 2
16	16		627.42393, F.S.; revising the circumstances under 3
17	17		which step-therapy protocols may not be required; 4
18	18		defining terms; requiring health insurers to publish 5
19	19		on their websites and provide to their insureds 6
20	20		specified information; providing requirements for 7
21	21		procedures for requests and appeals of denials of 8
22	22		protocol exemptions; providing requirements for 9
23	23		authorizations and denials of protocol exemption 10
24	24		requests; authorizing health insurers to request 11
25	25		specified documentation under certain circumstances; 12
26	26		amending s. 641.31, F.S.; revising the circumstances 13
27	27		under which step-therapy protocols may not be 14
28	28		required; defining terms; requiring health maintenance 15
29	29		organizations to publish on their websites and provide 16
30	30		to their subscribers specified information; providing 17
31	31		requirements for procedures for requests and appeals 18
32	32		of denials of protocol exemptions; providing 19
33	33		requirements for authorizations and denials of 20
34	34		protocol exemption requests; authorizing health 21
35	35		maintenance organizations to request specified 22
36	36		documentation under certain circumstances; providing 23
37	37		an effective date. 24
38	38		25
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40		-	HB 459 2022 ~~Legislature~~
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	40	+	HB 459 2022
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47	47		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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51	51		Be It Enacted by the Legislature of the Stat e of Florida: 26
52	52		27
53	53		Section 1. Section 627.42393, Florida Statutes, is amended 28
54	54		to read: 29
55	55		627.42393 Step-therapy protocol.— 30
56	56		(1)(2) As used in this section, the term : 31
57	57		(a) "Health coverage plan" means any of the following 32
58	58		which is currently or was previou sly providing major medical or 33
59	59		similar comprehensive coverage or benefits to the insured: 34
60	60		1.(a) A health insurer or health maintenance organization. 35
61	61		2.(b) A plan established or maintained by an individual 36
62	62		employer as provided by the Employee Retirement Income Security 37
63	63		Act of 1974, Pub. L. No. 93 -406. 38
64	64		3.(c) A multiple-employer welfare arrangement as defined 39
65	65		in s. 624.437. 40
66	66		4.(d) A governmental entity providing a plan of self -41
67	67		insurance. 42
68	68		(b) "Protocol exemption" means a determination by a health 43
69	69		insurer to authorize the use of another prescription drug, 44
70	70		medical procedure, or course of treatment prescribed or 45
71	71		recommended by the treating health care provider for the 46
72	72		insured's condition rather than the one specified by the health 47
73	73		insurer's step-therapy protocol. 48
74	74		(c) "Step-therapy protocol" means a written protocol that 49
75	75		specifies the order in which certain prescription drugs, medical 50
76		-	~~ENROLLED~~
77		-	HB 459 2022 ~~Legislature~~
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84	84		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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86	86
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88	88		procedures, or courses of treatment must be used to treat an 51
89	89		insured's condition. 52
90	90		(2)(1) In addition to the protocol exem ptions granted 53
91	91		under subsection (3), a health insurer issuing a major medical 54
92	92		individual or group policy may not require a step -therapy 55
93	93		protocol under the policy for a covered prescription drug 56
94	94		requested by an insured if: 57
95	95		(a) The insured has previously b een approved to receive 58
96	96		the prescription drug through the completion of a step -therapy 59
97	97		protocol required by a separate health coverage plan; and 60
98	98		(b) The insured provides documentation originating from 61
99	99		the health coverage plan that approved the prescription drug as 62
100	100		described in paragraph (a) indicating that the health coverage 63
101	101		plan paid for the drug on the insured's behalf during the 90 64
102	102		days immediately before the request. 65
103	103		(3)(a) A health insurer shall publish on its website and 66
104	104		provide to an insured in writing a procedure for the insured and 67
105	105		his or her health care provider to request a protocol exemption 68
106	106		or an appeal of the health insurer's denial of a protocol 69
107	107		exemption request. The procedure must include, at a minimum: 70
108	108		1. The manner in whic h the insured or health care provider 71
109	109		may request a protocol exemption, including a form to request 72
110	110		the protocol exemption. 73
111	111		2. The manner and timeframe in which the health insurer 74
112	112		authorizes or denies a protocol exemption request, which must 75
113		-	~~ENROLLED~~
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118	118		CODING: Words stricken are deletions; words underlined are additions.
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121	121		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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125	125		occur within a reasonable time. 76
126	126		3. The manner and timeframe in which the insured or health 77
127	127		care provider may appeal the health insurer's denial of a 78
128	128		protocol exemption request. 79
129	129		(b) An authorization of a protocol exemption request must 80
130	130		specify the approved prescrip tion drug, medical procedure, or 81
131	131		course of treatment. A denial of a protocol exemption request 82
132	132		must include a written explanation of the reason for the denial, 83
133	133		the clinical rationale that supports the denial, and the 84
134	134		procedure for appealing the health insu rer's denial. 85
135	135		(c) A health insurer may request relevant medical records 86
136	136		in support of a protocol exemption request. 87
137	137		(4)(3) This section does not require a health insurer to 88
138	138		add a drug to its prescription drug formulary or to cover a 89
139	139		prescription drug that the insurer does not otherwise cover. 90
140	140		Section 2. Subsection (46) of section 641.31, Florida 91
141	141		Statutes, is amended to read: 92
142	142		641.31 Health maintenance contracts. — 93
143	143		(46)(a)(b) As used in this subsection, the term : 94
144	144		1. "Health coverage plan" means a ny of the following which 95
145	145		previously provided or is currently providing major medical or 96
146	146		similar comprehensive coverage or benefits to the subscriber: 97
147	147		a.1. A health insurer or health maintenance organization .; 98
148	148		b.2. A plan established or maintained by a n individual 99
149	149		employer as provided by the Employee Retirement Income Security 100
150		-	~~ENROLLED~~
151		-	HB 459 2022 ~~Legislature~~
	150	+
	151	+	HB 459 2022
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158	158		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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162	162		Act of 1974, Pub. L. No. 93 -406.; 101
163	163		c.3. A multiple-employer welfare arrangement as defined in 102
164	164		s. 624.437.; or 103
165	165		d.4. A governmental entity providing a plan of self -104
166	166		insurance. 105
167	167		2. "Protocol exemption" means a determination by a health 106
168	168		maintenance organization to authorize the use of another 107
169	169		prescription drug, medical procedure, or course of treatment 108
170	170		prescribed or recommended by the treating health care provider 109
171	171		for the subscriber's condition rather than the one specified by 110
172	172		the health maintenance organization's step -therapy protocol. 111
173	173		3. "Step-therapy protocol" means a written protocol that 112
174	174		specifies the order in which certain prescription drugs, medical 113
175	175		procedures, or courses of treatment must be used to treat a 114
176	176		subscriber's condition. 115
177	177		(b)(a) In addition to the protocol exemptions granted 116
178	178		under paragraph (c), a health maintenance organization issuing 117
179	179		major medical coverage through an individual or group contract 118
180	180		may not require a step-therapy protocol under the contract for a 119
181	181		covered prescription drug requested by a subscriber if: 120
182	182		1. The subscriber has previously been approved to receive 121
183	183		the prescription drug through the completion of a step -therapy 122
184	184		protocol required by a sepa rate health coverage plan; and 123
185	185		2. The subscriber provides documentation originating from 124
186	186		the health coverage plan that approved the prescription drug as 125
187		-	~~ENROLLED~~
188		-	HB 459 2022 ~~Legislature~~
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195	195		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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199	199		described in subparagraph 1. indicating that the health coverage 126
200	200		plan paid for the drug on the subscr iber's behalf during the 90 127
201	201		days immediately before the request. 128
202	202		(c)1. A health maintenance organization shall publish on 129
203	203		its website and provide to a subscriber in writing a procedure 130
204	204		for the subscriber and his or her health care provider to 131
205	205		request a protocol exemption or an appeal of the health 132
206	206		maintenance organization's denial of a protocol exemption 133
207	207		request. The procedure must include, at a minimum: 134
208	208		a. The manner in which the subscriber or health care 135
209	209		provider may request a protocol exemption, incl uding a form to 136
210	210		request the protocol exemption. 137
211	211		b. The manner and timeframe in which the health 138
212	212		maintenance organization authorizes or denies a protocol 139
213	213		exemption request, which must occur within a reasonable time. 140
214	214		c. The manner and timeframe in which the subscriber or 141
215	215		health care provider may appeal the health maintenance 142
216	216		organization's denial of a protocol exemption request . 143
217	217		2. An authorization of a protocol exemption request must 144
218	218		specify the approved prescription drug, medical procedure, or 145
219	219		course of treatment. A denial of a protocol exemption request 146
220	220		must include a written explanation of the reason for the denial, 147
221	221		the clinical rationale that supports the denial, and the 148
222	222		procedure for appealing the health maintenance organization's 149
223	223		denial. 150
224		-	~~ENROLLED~~
225		-	HB 459 2022 ~~Legislature~~
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	225	+	HB 459 2022
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232	232		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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236	236		3. A health maintenance organization may request relevant 151
237	237		medical records in support of a protocol exemption request. 152
238	238		(d)(c) This subsection does not require a health 153
239	239		maintenance organization to add a drug to its prescription drug 154
240	240		formulary or to cover a prescr iption drug that the health 155
241	241		maintenance organization does not otherwise cover. 156
242	242		Section 3. This act shall take effect July 1, 2022. 157