HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 1 of 13
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 prescription drug coverage; 2
creating s. 627.42394, F.S.; requiring individual and 3
group health insurers to provide notice of 4
prescription drug formulary changes within a certain 5
timeframe to current and prospective insureds and the 6
insureds' treating physicians; specifying requirements 7
for the content of such notice and the manner in which 8
it must be provided; specifying requirements for a 9
notice of medical necessity submitted by the treating 10
physician; authorizing insurers to provide cer tain 11
means for submitting the notice of medical necessity; 12
requiring the Financial Services Commission to adopt a 13
certain form by rule by a specified date; specifying a 14
coverage requirement and restrictions on coverage 15
modification by insurers receiving a notice of medical 16
necessity; providing construction and applicability; 17
requiring insurers to maintain a record of formulary 18
changes; requiring insurers to annually submit a 19
specified report to the Office of Insurance Regulation 20
by a specified date; requiri ng the office to annually 21
compile certain data and prepare a report, make the 22
report publicly accessible on its website, and submit 23
the report to the Governor and the Legislature by a 24
specified date; amending s. 627.6699, F.S.; requiring 25
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 2 of 13
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
small employer carriers to comply with certain 26
requirements for prescription drug formulary changes; 27
amending s. 641.31, F.S.; providing an exception to 28
requirements relating to changes in a health 29
maintenance organization's group contract; requiring 30
health maintenance orga nizations to provide notice of 31
prescription drug formulary changes within a certain 32
timeframe to current and prospective subscribers and 33
the subscribers' treating physicians; specifying 34
requirements for the content of such notice and the 35
manner in which it must be provided; specifying 36
requirements for a notice of medical necessity 37
submitted by the treating physician; authorizing 38
health maintenance organizations to provide certain 39
means for submitting the notice of medical necessity; 40
requiring the commission to adopt a certain form by 41
rule by a specified date; specifying a coverage 42
requirement and restrictions on coverage modification 43
by health maintenance organizations receiving a notice 44
of medical necessity; providing construction and 45
applicability; requiri ng health maintenance 46
organizations to maintain a record of formulary 47
changes; requiring health maintenance organizations to 48
annually submit a specified report to the office by a 49
specified date; requiring the office to annually 50
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 3 of 13
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
compile certain data and pre pare a report, make the 51
report publicly accessible on its website, and submit 52
the report to the Governor and the Legislature by a 53
specified date; providing applicability; providing a 54
declaration of important state interest; providing an 55
effective date. 56
57
Be It Enacted by the Legislature of the State of Florida: 58
59
Section 1. Section 627.42394, Florida Statutes, is created 60
to read: 61
627.42394 Health insurance policies; changes to 62
prescription drug formularies; requirements. — 63
(1) At least 60 days be fore the effective date of any 64
change to a prescription drug formulary during a policy year, an 65
insurer issuing individual or group health insurance policies in 66
the state shall notify: 67
(a) Current and prospective insureds of the change in the 68
formulary in a readily accessible format on the insurer's 69
website; and 70
(b) Any insured currently receiving coverage for a 71
prescription drug for which the formulary change modifies 72
coverage and the insured's treating physician. Such notification 73
must be sent electro nically and by first -class mail and must 74
include information on the specific drugs involved and a 75
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 4 of 13
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
statement that the submission of a notice of medical necessity 76
by the insured's treating physician to the insurer at least 30 77
days before the effective date o f the formulary change will 78
result in continuation of coverage at the existing level. 79
(2) The notice provided by the treating physician to the 80
insurer must include a completed one -page form in which the 81
treating physician certifies to the insurer that th e 82
prescription drug for the insured is medically necessary as 83
defined in s. 627.732(2). The treating physician shall submit 84
the notice electronically or by first -class mail. The insurer 85
may provide the treating physician with access to an electronic 86
portal through which the treating physician may electronically 87
submit the notice. By January 1, 2025, the commission shall 88
adopt by rule a form for the notice. 89
(3) If the treating physician certifies to the insurer in 90
accordance with subsection (2) that the pr escription drug is 91
medically necessary for the insured, the insurer: 92
(a) Must authorize coverage for the prescribed drug until 93
the end of the policy year, based solely on the treating 94
physician's certification that the drug is medically necessary; 95
and 96
(b) May not modify the coverage related to the covered 97
drug during the policy year by: 98
1. Increasing the out -of-pocket costs for the covered 99
drug; 100
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 5 of 13
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
2. Moving the covered drug to a more restrictive tier; 101
3. Denying an insured coverage of the drug for w hich the 102
insured has been previously approved for coverage by the 103
insurer; or 104
4. Limiting or reducing coverage of the drug in any other 105
way, including subjecting it to a new prior authorization or 106
step-therapy requirement. 107
(4) Subsections (1), (2), and (3) do not: 108
(a) Prohibit the addition of prescription drugs to the 109
list of drugs covered under the policy during the policy year. 110
(b) Apply to a grandfathered health plan as defined in s. 111
627.402 or to benefits specified in s. 627.6513(1) -(14). 112
(c) Alter or amend s. 465.025, which provides conditions 113
under which a pharmacist may substitute a generically equivalent 114
drug product for a brand name drug product. 115
(d) Alter or amend s. 465.0252, which provides conditions 116
under which a pharmacist may dispe nse a substitute biological 117
product for the prescribed biological product. 118
(e) Apply to a Medicaid managed care plan under part IV of 119
chapter 409. 120
(5) A health insurer shall maintain a record of any change 121
in its formulary during a calendar year. By Ma rch 1 of each 122
year, a health insurer shall submit to the office a report 123
delineating such changes made in the previous calendar year. The 124
annual report must include, at a minimum: 125
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 6 of 13
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) A list of all drugs removed from the formulary and the 126
reasons for the removal; 127
(b) A list of all drugs moved to a tier resulting in 128
additional out-of-pocket costs to insureds; 129
(c) The number of insureds notified by the insurer of a 130
change in the formulary; and 131
(d) The increased cost, by dollar amount, incurred by 132
insureds because of such change in the formulary. 133
(6) By May 1 of each year, the office shall: 134
(a) Compile the data in the annual reports submitted by 135
health insurers under subsection (5) and prepare a report 136
summarizing the data submitted; 137
(b) Make the report publicly accessible on its website; 138
and 139
(c) Submit the report to the Governor, the President of 140
the Senate, and the Speaker of the House of Representatives. 141
Section 2. Paragraph (e) of subsection (5) of section 142
627.6699, Florida Statutes, is a mended to read: 143
627.6699 Employee Health Care Access Act. — 144
(5) AVAILABILITY OF COVERAGE. — 145
(e) All health benefit plans issued under this section 146
must comply with the following conditions: 147
1. For employers who have fewer than two employees, a late 148
enrollee may be excluded from coverage for no longer than 24 149
months if he or she was not covered by creditable coverage 150
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 7 of 13
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
continually to a date not more than 63 days before the effective 151
date of his or her new coverage. 152
2. Any requirement used by a small em ployer carrier in 153
determining whether to provide coverage to a small employer 154
group, including requirements for minimum participation of 155
eligible employees and minimum employer contributions, must be 156
applied uniformly among all small employer groups having the 157
same number of eligible employees applying for coverage or 158
receiving coverage from the small employer carrier, except that 159
a small employer carrier that participates in, administers, or 160
issues health benefits pursuant to s. 381.0406 which do not 161
include a preexisting condition exclusion may require as a 162
condition of offering such benefits that the employer has had no 163
health insurance coverage for its employees for a period of at 164
least 6 months. A small employer carrier may vary application of 165
minimum participation requirements and minimum employer 166
contribution requirements only by the size of the small employer 167
group. 168
3. In applying minimum participation requirements with 169
respect to a small employer, a small employer carrier shall not 170
consider as an eligible employee employees or dependents who 171
have qualifying existing coverage in an employer -based group 172
insurance plan or an ERISA qualified self -insurance plan in 173
determining whether the applicable percentage of participation 174
is met. However, a small em ployer carrier may count eligible 175
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 8 of 13
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
employees and dependents who have coverage under another health 176
plan that is sponsored by that employer. 177
4. A small employer carrier shall not increase any 178
requirement for minimum employee participation or any 179
requirement for minimum employer contribution applicable to a 180
small employer at any time after the small employer has been 181
accepted for coverage, unless the employer size has changed, in 182
which case the small employer carrier may apply the requirements 183
that are applicable to the new group size. 184
5. If a small employer carrier offers coverage to a small 185
employer, it must offer coverage to all the small employer's 186
eligible employees and their dependents. A small employer 187
carrier may not offer coverage limited to certai n persons in a 188
group or to part of a group, except with respect to late 189
enrollees. 190
6. A small employer carrier may not modify any health 191
benefit plan issued to a small employer with respect to a small 192
employer or any eligible employee or dependent throug h riders, 193
endorsements, or otherwise to restrict or exclude coverage for 194
certain diseases or medical conditions otherwise covered by the 195
health benefit plan. 196
7. An initial enrollment period of at least 30 days must 197
be provided. An annual 30 -day open enrollment period must be 198
offered to each small employer's eligible employees and their 199
dependents. A small employer carrier must provide special 200
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 9 of 13
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
enrollment periods as required by s. 627.65615. 201
8. A small employer carrier shall comply with s. 627.42394 202
for any change to a prescription drug formulary. 203
Section 3. Subsection (36) of section 641.31, Florida 204
Statutes, is amended to read: 205
641.31 Health maintenance contracts. — 206
(36) Except as provided in paragraphs (a), (b), and (c), a 207
health maintenance organization may increase the copayment for 208
any benefit, or delete, amend, or limit any of the benefits to 209
which a subscriber is entitled under the group contract only, 210
upon written notice to the contract holder at least 45 days in 211
advance of the time of coverage renewal. The health maintenance 212
organization may amend the contract with the contract holder, 213
with such amendment to be effective immediately at the time of 214
coverage renewal. The written notice to the contract holder must 215
shall specifically identify any deletions, amendments, or 216
limitations to any of the benefits provided in the group 217
contract during the current contract period which will be 218
included in the group contract upon renewal. This subsection 219
does not apply to any incr eases in benefits. The 45 -day notice 220
requirement does shall not apply if benefits are amended, 221
deleted, or limited at the request of the contract holder. 222
(a) At least 60 days before the effective date of any 223
change to a prescription drug formulary during a contract year, 224
a health maintenance organization shall notify: 225
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 10 of 13
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
1. Current and prospective subscribers of the change in 226
the formulary in a readily accessible format on the health 227
maintenance organization's website; and 228
2. Any subscriber currently rec eiving coverage for a 229
prescription drug for which the formulary change modifies 230
coverage and the subscriber's treating physician. Such 231
notification must be sent electronically and by first -class mail 232
and must include information on the specific drugs invol ved and 233
a statement that the submission of a notice of medical necessity 234
by the subscriber's treating physician to the health maintenance 235
organization at least 30 days before the effective date of the 236
formulary change will result in continuation of coverag e at the 237
existing level. 238
(b) The notice provided by the treating physician to the 239
health maintenance organization must include a completed one -240
page form in which the treating physician certifies to the 241
health maintenance organization that the prescriptio n drug for 242
the subscriber is medically necessary as defined in s. 243
627.732(2). The treating physician shall submit the notice 244
electronically or by first -class mail. The health maintenance 245
organization may provide the treating physician with access to 246
an electronic portal through which the treating physician may 247
electronically submit the notice. By January 1, 2025, the 248
commission shall adopt by rule a form for the notice. 249
(c) If the treating physician certifies to the health 250
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 11 of 13
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
maintenance organization in acco rdance with paragraph (b) that 251
the prescription drug is medically necessary for the subscriber, 252
the health maintenance organization: 253
1. Must authorize coverage for the prescribed drug until 254
the end of the contract year, based solely on the treating 255
physician's certification that the drug is medically necessary; 256
and 257
2. May not modify the coverage related to the covered drug 258
during the contract year by: 259
a. Increasing the out -of-pocket costs for the covered 260
drug; 261
b. Moving the covered drug to a more re strictive tier; 262
c. Denying a subscriber coverage of the drug for which the 263
subscriber has been previously approved for coverage by the 264
health maintenance organization; or 265
d. Limiting or reducing coverage of the drug in any other 266
way, including subjecti ng it to a new prior authorization or 267
step-therapy requirement. 268
(d) Paragraphs (a), (b), and (c) do not: 269
1. Prohibit the addition of prescription drugs to the list 270
of drugs covered under the contract during the contract year. 271
2. Apply to a grandfathe red health plan as defined in s. 272
627.402 or to benefits specified in s. 627.6513(1) -(14). 273
3. Alter or amend s. 465.025, which provides conditions 274
under which a pharmacist may substitute a generically equivalent 275
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 12 of 13
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
drug product for a brand name drug product. 276
4. Alter or amend s. 465.0252, which provides conditions 277
under which a pharmacist may dispense a substitute biological 278
product for the prescribed biological product. 279
5. Apply to a Medicaid managed care plan under part IV of 280
chapter 409. 281
(e) A health maintenance organization shall maintain a 282
record of any change in its formulary during a calendar year. By 283
March 1 of each year, a health maintenance organization shall 284
submit to the office a report delineating such changes made in 285
the previous calendar y ear. The annual report must include, at a 286
minimum: 287
1. A list of all drugs removed from the formulary and the 288
reasons for the removal; 289
2. A list of all drugs moved to a tier resulting in 290
additional out-of-pocket costs to subscribers; 291
3. The number of subscribers notified by the health 292
maintenance organization of a change in the formulary; and 293
4. The increased cost, by dollar amount, incurred by 294
subscribers because of such change in the formulary. 295
(f) By May 1 of each year, the office shall: 296
1. Compile the data in such annual reports submitted by 297
health maintenance organizations and prepare a report 298
summarizing the data submitted; 299
2. Make the report publicly accessible on its website; and 300
HB 1543 2024
CODING: Words stricken are deletions; words underlined are additions.
hb1543-00
Page 13 of 13
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
3. Submit the report to the Governor, the President of t he 301
Senate, and the Speaker of the House of Representatives. 302
Section 4. This act applies to health insurance policies, 303
health benefit plans, and health maintenance contracts entered 304
into or renewed on or after January 1, 2025. 305
Section 5. The Legislature finds that this act fulfills an 306
important state interest. 307
Section 6. This act shall take effect January 1, 2025. 308