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A bill to be entitled 1
An act relating to access to pharmacies and 2
prescription drugs under insurance and pharmacy 3
benefit managers policies; amending s. 624.3161, F.S.; 4
requiring the Office of Insurance Regulation to 5
examine pharmacy benefit managers to ascertain 6
compliance with specified laws; conforming a provision 7
to changes made by the act; amending s. 624.490, F.S.; 8
requiring the office to suspend or revoke 9
registrations for pharmacy benefit managers and impose 10
fines and civil penalties for certain violations; 11
providing fines and civil penalties; providing that 12
such violations are unfair methods of competition or 13
unfair or deceptive acts or practices; providing that 14
such violations are subject to certain actions, 15
remedies, and penalties; providing applicability; 16
creating s. 624.4901, F.S.; providing purpose; 17
providing definitions; requiring pharmacy benefit 18
managers to establish pharmacy benefit networks for a 19
specified purpose; requiring pharmacy benefit managers 20
to have standard contracts with pharmacies; providing 21
requirements for such contracts' terms and conditions; 22
requiring pharmacy benefit managers to provide copies 23
of such standard contracts within a specified 24
timeframe to requesting pharmacies and pharmacists; 25
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prohibiting pharmacy benefit managers from denying 26
pharmacies and pharmacists in the state the right to 27
participate as contract providers under certain 28
circumstances; providing construction; authorizing 29
certain persons and entities to bring actions and 30
injunctive relief under certain circumstances; 31
authorizing the Department of Financial Services to 32
adopt rules; creating s. 624.4902, F.S.; providing 33
purpose; providing definitions; prohibiting pharmacy 34
benefit managers from engaging in certain acts against 35
patients and covered individuals; providing that such 36
acts are unfair methods of competition or unfair or 37
deceptive acts or practices; providing that such acts 38
are subject to certain actions, remedies, and 39
penalties; authorizing the department to adopt rules; 40
creating s. 627.42398, F.S.; providing definitions; 41
prohibiting health insurers and pharmacy benefit 42
managers from engaging in certain acts relating to 43
covered clinician-administered drugs; providing that 44
such acts constitute unfair methods of competition or 45
unfair or deceptive acts or practices and are subje ct 46
to certain actions, remedies, and penalties; providing 47
an effective date. 48
49
Be It Enacted by the Legislature of the State of Florida: 50
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Section 1. Subsections (1) and (3) of section 624.3161, 52
Florida Statutes, are amended to read: 53
624.3161 Market conduct examinations. — 54
(1) As often as it deems necessary, the office shall 55
examine each pharmacy benefit manager as defined in s. 624.490, 56
each licensed rating organization, each advisory organization, 57
each group, association, carrier, as defined in s . 440.02, or 58
other organization of insurers which engages in joint 59
underwriting or joint reinsurance, and each authorized insurer 60
transacting in this state any class of insurance to which the 61
provisions of chapter 627 are applicable. The examination shall 62
be for the purpose of ascertaining compliance by the person 63
examined with the applicable provisions of chapters 440, 624, 64
626, 627, and 635. 65
(3) The examination may be conducted by an independent 66
professional examiner under contract to the office, in whi ch 67
case payment shall be made directly to the contracted examiner 68
by the entity insurer examined in accordance with the rates and 69
terms agreed to by the office and the examiner. 70
Section 2. Subsections (6) and (7) of section 624.490, 71
Florida Statutes, are renumbered as subsections (8) and (9), 72
respectively, and new subsections (6) and (7) are added to that 73
section, to read: 74
624.490 Registration of pharmacy benefit managers. — 75
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(6)(a) The office may suspend or revoke a pharmacy benefit 76
manager's registration or impose a fine or civil penalty if it 77
finds that the pharmacy benefit manager has violated s. 78
624.4901, s. 624.4902, s. 624.491, s. 627.42398, s. 627.6131, s. 79
627.64741, s. 627.6572, s. 641.314, or s. 641.3155. The fine or 80
civil penalty shall be in the amount of $10,000 for each 81
violation, which shall accrue for each day the pharmacy benefit 82
manager is in violation of the law. 83
(b) The violation of any section enumerated in paragraph 84
(a) constitutes an unfair method of competition or an unfair or 85
deceptive act or practice, subject to actions, remedies, and 86
penalties provided by the Florida Deceptive and Unfair Trade 87
Practices Act and consumer protection laws. 88
(7) Subsection (6) applies to contracts between a pharmacy 89
benefit manager and a pharmacy that participates in a retail 90
pharmacy network of the pharmacy benefit manager. 91
Section 3. Section 624.4901, Florida Statutes, is created 92
to read: 93
624.4901 Pharmacy benefit manager contracts with 94
pharmacies.— 95
(1) The purpose of this section is to give patients 96
convenient access to affordable prescription drugs through a 97
pharmacy of their choice. 98
(2) As used in this section, the term: 99
(a) "Affiliate" means a pharmacy in which a pharmacy 100
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benefit manager, directly or indirectly, has an investment or 101
ownership interest or shares common ownership. 102
(b) "Pharmacy" means a pharmacy licensed under chapter 103
465, a nonresident pharmacy registered under s. 465.0156, or a 104
nonresident pharmacy or outsourcing facility holding an active 105
permit pursuant to s. 4 65.0158 to dispense drugs to patients 106
located in this state. 107
(c) "Pharmacy benefit manager" has the same meaning as in 108
s. 624.490(1). 109
(3) A pharmacy benefit manager shall establish a 110
reasonably adequate and accessible pharmacy benefit network to 111
provide patients with convenient access to prescription drugs 112
through pharmacies that are located within a reasonable distance 113
from a patient's residence. 114
(4) A pharmacy benefit manager shall have a standard 115
contract with reasonable and relevant terms and cond itions of 116
participation in the pharmacy benefit network, whereby any 117
willing pharmacy may participate as a network pharmacy. Terms 118
and conditions must include provisions reasonable and relevant 119
to unique pharmacy, pharmacy business, and pharmacy service 120
models. 121
(5) A pharmacy benefit manager shall provide a copy of the 122
standard contract to a requesting pharmacy or pharmacist within 123
7 business days after receiving such a request from the pharmacy 124
or pharmacist. 125
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(6) If a pharmacy benefit manager's affilia te participates 126
in the pharmacy benefit network, the pharmacy benefit manager 127
may not deny another pharmacy or pharmacist in this state the 128
right to participate as a contract provider under the policy or 129
plan, provided that the pharmacy or pharmacist agree s to: 130
(a) Provide pharmaceutical services that meet all 131
reasonable and relevant terms and conditions. 132
(b) Include the same administrative, financial, and 133
professional conditions that apply to pharmacy and pharmacists 134
that have been designated as provid ers under the policy or plan. 135
(7) The decision of a pharmacy or pharmacist to accept a 136
contract with the pharmacy benefit manager is not admissible 137
proof that the contract is reasonable and relevant. 138
(8) Without regard to any other remedy or relief to which 139
a pharmacy is entitled, a pharmacy, a pharmacist, or a person, 140
firm, corporation, association, entity, or any agent or employee 141
of a pharmacy or pharmacist which is aggrieved by a violation of 142
this section may bring an action to recover damages, plus 143
attorney fees and costs, and injunctive relief. 144
(9) The department may adopt rules to implement this 145
section. 146
Section 4. Section 624.4902, Florida Statutes, is created 147
to read: 148
624.4902 Pharmacy benefit managers' prohibited acts. — 149
(1) The purpose of this section is to protect patient 150
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welfare by establishing minimum standards for patient access to 151
a pharmacy provider and by prohibiting restrictions imposed by a 152
pharmacy benefit manager on a patient's right to choose a 153
pharmacy. 154
(2) As used in this section, the term: 155
(a) "Affiliate" means a pharmacy in which a pharmacy 156
benefit manager, directly or indirectly, has an investment or 157
ownership interest or shares common ownership. As used in this 158
paragraph, the term "pharmacy" has the same meaning as in s. 159
624.4901(2). 160
(b) "Pharmacy benefit manager" has the same meaning as in 161
s. 624.490(1). 162
(c) "Wholesale acquisition cost" means the amount that a 163
pharmaceutical wholesaler charges for a pharmaceutical product 164
as listed on the pharmacy's billing inv oice. 165
(3) A pharmacy benefit manager may not: 166
(a) Offer, incentivize, or implement a plan design that 167
requires a patient or covered individual to use an affiliate; 168
(b) Refer or incentivize a patient or covered individual 169
to use an affiliate or any ph armacy in which the pharmacy 170
benefit manager has any direct or indirect financial interest or 171
ownership; 172
(c) Restrict the choice of a patient or covered individual 173
of an in-network provider for prescription drugs; 174
(d) Reimburse a pharmacy or pharmacist in this state an 175
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amount less than the amount that the pharmacy benefit manager 176
reimburses an affiliate for providing the same drug products, 177
drug product ingredients, or pharmacist services; or 178
(e) Reimburse a pharmacy or pharmacist in this state for a 179
drug product, drug product ingredient, or pharmacist services an 180
amount less than the national average drug acquisition cost, or, 181
if the national average drug acquisition cost is unavailable, 182
the wholesale acquisition cost. 183
(4) The commission of any act prohibited under subsection 184
(3) constitutes an unfair method of competition or an unfair or 185
deceptive act or practice, subject to actions, remedies, and 186
penalties provided by the Florida Deceptive and Unfair Trade 187
Practices Act and consumer protection laws . 188
(5) The department may adopt rules necessary to implement 189
this section. 190
Section 5. Section 627.42398, Florida Statutes, is created 191
to read: 192
627.42398 Coverage of clinician -administered drugs by 193
health insurers and pharmacy benefit managers. — 194
(1) As used in this section, the term: 195
(a) "Clinician-administered drug" means a prescription 196
drug other than a vaccine which: 197
1. Has not been approved by the United States Food and 198
Drug Administration as a self -administered drug or self -199
administered biologic, or cannot reasonably be administered by 200
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the patient to whom the drug is prescribed or by an individual 201
other than a health care provider. 202
2. Is typically administered in a physician's office, 203
hospital, outpatient infusion center, or other clinical setting. 204
(b) "Health care provider" means a health care 205
professional, health care facility, or entity licensed or 206
certified to provide health care services in this state which 207
meets the criteria established by the Department of Health. 208
(c) "Insurer" means an insurer as defined in s. 624.03 209
which provides health insurance coverage, a multiple -employer 210
welfare arrangement as def ined in s. 624.437(1), self -insurance 211
as defined in s. 624.031, a prepaid limited health service 212
organization as defined in s. 636.003(7), a health maintenance 213
organization as defined in s. 641.19(12), a prepaid health 214
clinic as defined in s. 641.402, a fr aternal benefit society as 215
defined in s. 632.601 which provides health care benefits, or 216
any health care arrangement that assumes some risk. 217
(d) "Participating provider" means a health care provider 218
that participates in the network of an insurer or pharm acy 219
benefit manager. 220
(e) "Pharmacy benefit manager" has the same meaning as in 221
s. 624.490(1). 222
(f) "White bagging" means the policy of an insurer or 223
pharmacy benefit manager which requires a prescription drug to 224
be: 225
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1. Dispensed by a specialty pharmac y selected by the 226
insurer or pharmacy benefit manager. 227
2. Transported to a health care provider for 228
administration to a patient. 229
230
As used in this paragraph, the term "specialty pharmacy" means a 231
pharmacy that focuses on high -cost medications and personal ized 232
support for patients with chronic or complex conditions. 233
(2) An insurer or pharmacy benefit manager that covers a 234
clinician-administered drug may not: 235
(a) Condition, deny, or reduce payment to a participating 236
provider for providing the covered cli nician-administered drug 237
and related services to an insured if all the criteria for the 238
medical necessity for providing and administering the clinician -239
administered drug are met, regardless of whether the clinician -240
administered drug is obtained from a phar macy selected by the 241
insurer or pharmacy benefit manager. For the purposes of this 242
section, the location of receiving the clinician -administered 243
drug may not be considered a medical necessity criterion. 244
(b) Interfere with the insured's right to choose to obtain 245
the covered clinician -administered drug from a participating 246
provider or a pharmacy of choice, through any inducement, 247
steering, or financial or other incentive offer. 248
(c) Require the covered clinician -administered drug to be 249
dispensed by a pharm acy selected by the insurer or pharmacy 250
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benefit manager, including, but not limited to, through white 251
bagging. 252
(d) If the covered clinician -administered drug is not 253
dispensed by a pharmacy selected by the insurer or pharmacy 254
benefit manager: 255
1. Reimburse for the clinician -administered drug at a 256
lesser amount than the amount that would otherwise be 257
reimbursed; 258
2. Limit or exclude coverage or benefits for the 259
clinician-administered drug; or 260
3. Require the insured to pay an additional fee, a higher 261
copayment, a higher coinsurance, a second copayment, a second 262
coinsurance, or any other form of an increased cost -sharing 263
amount over the price paid for the clinician -administered drug 264
dispensed by a pharmacy selected by the insurer or pharmacy 265
benefit manager. 266
(e) Require that the covered clinician -administered drug 267
be administered using home infusion or be sent directly to a 268
third party or to the insured for home infusion, unless the 269
insured's treating physician determines that home infusion of 270
the clinician-administered drug will not jeopardize the 271
insured's health. 272
(3) The commission of any act prohibited under subsection 273
(2) constitutes an unfair method of competition or an unfair or 274
deceptive act or practice, subject to actions, remedies, and 275
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penalties provided by the Florida Deceptive and Unfair Trade 276
Practices Act and consumer protection laws. 277
Section 6. This act shall take effect July 1, 2023. 278