HB 363 2024
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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 bill to be entitled 1
An act relating to health insurance cost sharing; 2
creating s. 627.6383, F.S.; defining the term "cost -3
sharing requirement"; requiring specified individual 4
health insurers and their pharmacy benefit managers to 5
apply payments for prescription drugs by or on behalf 6
of insureds toward the total contributions of the 7
insureds' cost-sharing requirements under certain 8
circumstances; providing construction; providin g 9
applicability; amending s. 627.6385, F.S.; providing 10
disclosure requirements; providing applicability; 11
amending s. 627.64741, F.S.; requiring specified 12
contracts to require pharmacy benefit managers to 13
apply payments by or on behalf of insureds toward th e 14
insureds' total contributions to cost -sharing 15
requirements; providing applicability; providing 16
disclosure requirements; creating s. 627.65715, F.S.; 17
defining the term "cost -sharing requirement"; 18
requiring specified group health insurers and their 19
pharmacy benefit managers to apply payments for 20
prescription drugs by or on behalf of insureds toward 21
the total contributions of the insureds' cost -sharing 22
requirements under certain circumstances; providing 23
construction; providing disclosure requirements; 24
providing applicability; amending s. 627.6572, F.S.; 25
HB 363 2024
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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
requiring specified contracts to require pharmacy 26
benefit managers to apply payments by or on behalf of 27
insureds toward the insureds' total contributions to 28
cost-sharing requirements; providing applicability; 29
providing disclosure requirements; amending s. 30
627.6699, F.S.; making technical changes; requiring 31
small employer carriers to comply with certain cost -32
sharing requirements; amending s. 641.31, F.S.; 33
defining the term "cost -sharing requirement"; 34
requiring specified health maintenance organizations 35
and their pharmacy benefit managers to apply payments 36
for prescription drugs by or on behalf of subscribers 37
toward the total contributions of the subscribers' 38
cost-sharing requirements under certain circumstances; 39
providing construction; providing disclosure 40
requirements; providing applicability; amending s. 41
641.314, F.S.; requiring specified contracts to 42
require pharmacy benefit managers to apply payments by 43
or on behalf of subscribers toward the subscribers' 44
total contributions to cost -sharing requirements; 45
providing applicability; providing disclosure 46
requirements; amending s. 409.967, F.S.; conforming a 47
cross-reference; amending s. 641.185, F.S.; conforming 48
a provision to changes made by the act; providing a 49
declaration of important state interest; providing an 50
HB 363 2024
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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
effective date. 51
52
Be It Enacted by the Legislature of the State of Florida: 53
54
Section 1. Section 627.6383, Florida Statutes, is created 55
to read: 56
627.6383 Cost-sharing requirements. — 57
(1) As used in this section, the term "cost -sharing 58
requirement" means a dollar limit, a deductible, a copayment, 59
coinsurance, or any other out -of-pocket expense imposed on an 60
insured, including, but not limited to, the annual limitation on 61
cost sharing subject to 42 U. S.C. s. 18022. 62
(2)(a) Each health insurer issuing, delivering, or 63
renewing a policy in this state which provides prescription drug 64
coverage, or each pharmacy benefit manager on behalf of such 65
health insurer, shall apply any amount paid for a prescription 66
drug by an insured or by another person on behalf of the insured 67
toward the insured's total contribution to any cost -sharing 68
requirement, if the prescription drug: 69
1. Does not have a generic equivalent; or 70
2. Has a generic equivalent and the insured h as obtained 71
authorization for the prescription drug through any of the 72
following: 73
a. Prior authorization from the health insurer or pharmacy 74
benefit manager. 75
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b. A step-therapy protocol. 76
c. The exception or appeal process of the health insurer 77
or pharmacy benefit manager. 78
(b) The amount paid by or on behalf of the insured which 79
is applied toward the insured's total contribution to any cost -80
sharing requirement under paragraph (a) includes, but is not 81
limited to, any payment with or any discount throug h financial 82
assistance, a manufacturer copay card, a product voucher, or any 83
other reduction in out -of-pocket expenses made by or on behalf 84
of the insured for a prescription drug. 85
(3) This section applies to any health insurance policy 86
issued, delivered, or renewed in this state on or after January 87
1, 2025. 88
Section 2. Subsections (2) and (3) of section 627.6385, 89
Florida Statutes, are renumbered as subsections (3) and (4), 90
respectively, present subsection (2) of that section is amended, 91
and a new subsection (2) is added to that section, to read: 92
627.6385 Disclosures to policyholders; calculations of 93
cost sharing.— 94
(2) Each health insurer issuing, delivering, or renewing a 95
policy in this state which provides prescription drug coverage, 96
regardless of whether the prescription drug benefits are 97
administered or managed by the health insurer or by a pharmacy 98
benefit manager on behalf of the health insurer, shall disclose 99
on its website that any amount paid by a policyholder or by 100
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another person on behalf of the policyholder must be applied 101
toward the policyholder's total contribution to any cost -sharing 102
requirement pursuant to s. 627.6383. This subsection applies to 103
any policy issued, delivered, or renewed in this state on or 104
after January 1, 2025. 105
(3)(2) Each health insurer shall include in every policy 106
delivered or issued for delivery to any person in this the state 107
or in materials provided as required by s. 627.64725 a notice 108
that the information required by this section is available 109
electronically and the website address of the website where the 110
information can be accessed. In addition, each health insurer 111
issuing, delivering, or renewing a policy in this state which 112
provides prescription drug coverage, regardless of whether the 113
prescription drug benefits are administered or managed by the 114
health insurer or by a pharmacy benefit manager on behalf of the 115
health insurer, shall disclose in every policy that is issued, 116
delivered, or renewed to any person in this state on or after 117
January 1, 2025, that any amount paid by a policyholder or by 118
another person on behalf of the policyholder must be applied 119
toward the policyholder's total contribution to any cost -sharing 120
requirement pursuant to s. 627.6383. 121
Section 3. Paragraph (c) is added to subsec tion (2) of 122
section 627.64741, Florida Statutes, to read: 123
627.64741 Pharmacy benefit manager contracts. — 124
(2) In addition to the requirements of part VII of chapter 125
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626, a contract between a health insurer and a pharmacy benefit 126
manager must require tha t the pharmacy benefit manager: 127
(c)1. Apply any amount paid by an insured or by another 128
person on behalf of the insured toward the insured's total 129
contribution to any cost -sharing requirement pursuant to s. 130
627.6383. This subparagraph applies to any insu red whose 131
insurance policy is issued, delivered, or renewed in this state 132
on or after January 1, 2025. 133
2. Disclose to every insured whose insurance policy is 134
issued, delivered, or renewed in this state on or after January 135
1, 2025, that the pharmacy benef it manager shall apply any 136
amount paid by the insured or by another person on behalf of the 137
insured toward the insured's total contribution to any cost -138
sharing requirement pursuant to s. 627.6383. 139
Section 4. Section 627.65715, Florida Statutes, is create d 140
to read: 141
627.65715 Cost-sharing requirements. — 142
(1) As used in this section, the term "cost -sharing 143
requirement" means a dollar limit, a deductible, a copayment, 144
coinsurance, or any other out -of-pocket expense imposed on an 145
insured, including, but not limited to, the annual limitation on 146
cost sharing subject to 42 U.S.C. s. 18022. 147
(2)(a) Each insurer issuing, delivering, or renewing a 148
policy in this state which provides prescription drug coverage, 149
or each pharmacy benefit manager on behalf of such in surer, 150
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shall apply any amount paid for a prescription drug by an 151
insured or by another person on behalf of the insured toward the 152
insured's total contribution to any cost -sharing requirement, if 153
the prescription drug: 154
1. Does not have a generic equivalen t; or 155
2. Has a generic equivalent and the insured has obtained 156
authorization for the prescription drug through any of the 157
following: 158
a. Prior authorization from the health insurer or pharmacy 159
benefit manager. 160
b. A step-therapy protocol. 161
c. The exception or appeal process of the health insurer 162
or pharmacy benefit manager. 163
(b) The amount paid by or on behalf of the insured which 164
is applied toward the insured's total contribution to any cost -165
sharing requirement under paragraph (a) includes, but is no t 166
limited to, any payment with or any discount through financial 167
assistance, a manufacturer copay card, a product voucher, or any 168
other reduction in out -of-pocket expenses made by or on behalf 169
of the insured for a prescription drug. 170
(3) Each insurer issu ing, delivering, or renewing a policy 171
in this state which provides prescription drug coverage, 172
regardless of whether the prescription drug benefits are 173
administered or managed by the insurer or by a pharmacy benefit 174
manager on behalf of the insurer, shall disclose on its website 175
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and in every policy issued, delivered, or renewed in this state 176
on or after January 1, 2025, that any amount paid by an insured 177
or by another person on behalf of the insured must be applied 178
toward the insured's total contribution to any cost-sharing 179
requirement. 180
(4) This section applies to any group health insurance 181
policy issued, delivered, or renewed in this state on or after 182
January 1, 2025. 183
Section 5. Paragraph (c) is added to subsection (2) of 184
section 627.6572, Florida Statu tes, to read: 185
627.6572 Pharmacy benefit manager contracts. — 186
(2) In addition to the requirements of part VII of chapter 187
626, a contract between a health insurer and a pharmacy benefit 188
manager must require that the pharmacy benefit manager: 189
(c)1. Apply any amount paid by an insured or by another 190
person on behalf of the insured toward the insured's total 191
contribution to any cost -sharing requirement pursuant to s. 192
627.65715. This subparagraph applies to any insured whose 193
insurance policy is issued, delive red, or renewed in this state 194
on or after January 1, 2025. 195
2. Disclose to every insured whose insurance policy is 196
issued, delivered, or renewed in this state on or after January 197
1, 2025, that the pharmacy benefit manager shall apply any 198
amount paid by the insured or by another person on behalf of the 199
insured toward the insured's total contribution to any cost -200
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sharing requirement pursuant to s. 627.65715. 201
Section 6. Paragraph (e) of subsection (5) of section 202
627.6699, Florida Statutes, is amended to read : 203
627.6699 Employee Health Care Access Act. — 204
(5) AVAILABILITY OF COVERAGE. — 205
(e) All health benefit plans issued under this section 206
must comply with the following conditions: 207
1. For employers who have fewer than two employees, a late 208
enrollee may be excluded from coverage for no longer than 24 209
months if he or she was not covered by creditable coverage 210
continually to a date not more than 63 days before the effective 211
date of his or her new coverage. 212
2. Any requirement used by a small employer carrier in 213
determining whether to provide coverage to a small employer 214
group, including requirements for minimum participation of 215
eligible employees and minimum employer contributions, must be 216
applied uniformly among all small employer groups having the 217
same number of eligible employees applying for coverage or 218
receiving coverage from the small employer carrier, except that 219
a small employer carrier that participates in, administers, or 220
issues health benefits purs uant to s. 381.0406 which do not 221
include a preexisting condition exclusion may require as a 222
condition of offering such benefits that the employer has had no 223
health insurance coverage for its employees for a period of at 224
least 6 months. A small employer car rier may vary application of 225
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minimum participation requirements and minimum employer 226
contribution requirements only by the size of the small employer 227
group. 228
3. In applying minimum participation requirements with 229
respect to a small employer, a small emplo yer carrier may shall 230
not consider as an eligible employee employees or dependents who 231
have qualifying existing coverage in an employer -based group 232
insurance plan or an ERISA qualified self -insurance plan in 233
determining whether the applicable percentage of participation 234
is met. However, a small employer carrier may count eligible 235
employees and dependents who have coverage under another health 236
plan that is sponsored by that employer. 237
4. A small employer carrier may shall not increase any 238
requirement for minimum employee participation or any 239
requirement for minimum employer contribution applicable to a 240
small employer at any time after the small employer has been 241
accepted for coverage, unless the employer size has changed, in 242
which case the small employer car rier may apply the requirements 243
that are applicable to the new group size. 244
5. If a small employer carrier offers coverage to a small 245
employer, it must offer coverage to all the small employer's 246
eligible employees and their dependents. A small employer 247
carrier may not offer coverage limited to certain persons in a 248
group or to part of a group, except with respect to late 249
enrollees. 250
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6. A small employer carrier may not modify any health 251
benefit plan issued to a small employer with respect to a small 252
employer or any eligible employee or dependent through riders, 253
endorsements, or otherwise to restrict or exclude coverage for 254
certain diseases or medical conditions otherwise covered by the 255
health benefit plan. 256
7. An initial enrollment period of at least 30 day s must 257
be provided. An annual 30 -day open enrollment period must be 258
offered to each small employer's eligible employees and their 259
dependents. A small employer carrier must provide special 260
enrollment periods as required by s. 627.65615. 261
8. A small employer carrier shall comply with s. 627.65715 262
with respect to contribution to cost -sharing requirements, as 263
defined in that section. 264
Section 7. Subsection (48) is added to section 641.31, 265
Florida Statutes, to read: 266
641.31 Health maintenance contracts. — 267
(48)(a) As used in this subsection, the term "cost -sharing 268
requirement" means a dollar limit, a deductible, a copayment, 269
coinsurance, or any other out -of-pocket expense imposed on a 270
subscriber, including, but not limited to, the annual limitation 271
on cost sharing subject to 42 U.S.C. s. 18022. 272
(b)1. Each health maintenance organization issuing, 273
delivering, or renewing a health maintenance contract or 274
certificate in this state which provides prescription drug 275
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coverage, or each pharmacy benefit manager on behalf of such 276
health maintenance organization, shall apply any amount paid for 277
a prescription drug by a subscriber or by another person on 278
behalf of the subscriber toward the subscriber's total 279
contribution to any cost-sharing requirement if the prescription 280
drug: 281
a. Does not have a generic equivalent; or 282
b. Has a generic equivalent and the subscriber has 283
obtained authorization for the prescription drug through any of 284
the following: 285
(I) Prior authorizatio n from the health maintenance 286
organization or pharmacy benefit manager. 287
(II) A step-therapy protocol. 288
(III) The exception or appeal process of the health 289
maintenance organization or pharmacy benefit manager. 290
2. The amount paid by or on behalf of the subscriber which 291
is applied toward the subscriber's total contribution to any 292
cost-sharing requirement under subparagraph 1. includes, but is 293
not limited to, any payment with or any discount through 294
financial assistance, a manufacturer copay card, a produc t 295
voucher, or any other reduction in out -of-pocket expenses made 296
by or on behalf of the subscriber for a prescription drug. 297
(c) Each health maintenance organization issuing, 298
delivering, or renewing a health maintenance contract or 299
certificate in this sta te which provides prescription drug 300
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coverage, regardless of whether the prescription drug benefits 301
are administered or managed by the health maintenance 302
organization or by a pharmacy benefit manager on behalf of the 303
health maintenance organization, shall d isclose on its website 304
and in every subscriber's health maintenance contract, 305
certificate, or member handbook issued, delivered, or renewed in 306
this state on or after January 1, 2025, that any amount paid by 307
a subscriber or by another person on behalf of th e subscriber 308
must be applied toward the subscriber's total contribution to 309
any cost-sharing requirement. 310
(d) This subsection applies to any health maintenance 311
contract or certificate issued, delivered, or renewed in this 312
state on or after January 1, 2025 . 313
Section 8. Paragraph (c) is added to subsection (2) of 314
section 641.314, Florida Statutes, to read: 315
641.314 Pharmacy benefit manager contracts. — 316
(2) In addition to the requirements of part VII of chapter 317
626, a contract between a health maintenance organization and a 318
pharmacy benefit manager must require that the pharmacy benefit 319
manager: 320
(c)1. Apply any amount paid by a subscriber or by another 321
person on behalf of the subscriber toward the subscriber's total 322
contribution to any cost -sharing requirement pursuant to s. 323
641.31(48). This subparagraph applies to any subscriber whose 324
health maintenance contract or certificate is issued, delivered, 325
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or renewed in this state on or after January 1, 2025. 326
2. Disclose to every subscriber whose health mainten ance 327
contract or certificate is issued, delivered, or renewed in this 328
state on or after January 1, 2025, that the pharmacy benefit 329
manager shall apply any amount paid by the subscriber or by 330
another person on behalf of the subscriber toward the 331
subscriber's total contribution to any cost -sharing requirement 332
pursuant to s. 641.31(48). 333
Section 9. Paragraph (o) of subsection (2) of section 334
409.967, Florida Statutes, is amended to read: 335
409.967 Managed care plan accountability. — 336
(2) The agency shall estab lish such contract requirements 337
as are necessary for the operation of the statewide managed care 338
program. In addition to any other provisions the agency may deem 339
necessary, the contract must require: 340
(o) Transparency.—Managed care plans shall comply with ss. 341
627.6385(4) and 641.54(7) ss. 627.6385(3) and 641.54(7) . 342
Section 10. Paragraph (k) of subsection (1) of section 343
641.185, Florida Statutes, is amended to read: 344
641.185 Health maintenance organization subscriber 345
protections.— 346
(1) With respect to the provisions of this part and part 347
III, the principles expressed in the following statements serve 348
as standards to be followed by the commission, the office, the 349
department, and the Agency for Health Care Administration in 350
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exercising their powers and duties, in exercising administrative 351
discretion, in administrative interpretations of the law, in 352
enforcing its provisions, and in adopting rules: 353
(k) A health maintenance organization subscriber shall be 354
given a copy of the applicable health maintenance contract, 355
certificate, or member handbook specifying: all the provisions, 356
disclosure, and limitations required pursuant to s. 641.31(1) , 357
and (4), and (48); the covered services, including those 358
services, medical conditions, and provider types specified in 359
ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 360
641.513; and where and in what manner services may be obtained 361
pursuant to s. 641.31(4). 362
Section 11. The Legislature finds that this act fulfills 363
an important state interest. 364
Section 12. This act shall take effect July 1, 2024. 365