Florida 2024 Regular Session

Florida House Bill H1543 Compare Versions

Only one version of the bill is available at this time.

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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	14	A bill to be entitled 1
15	15	An act relating to prescription drug coverage; 2
16	16	creating s. 627.42394, F.S.; requiring individual and 3
17	17	group health insurers to provide notice of 4
18	18	prescription drug formulary changes within a certain 5
19	19	timeframe to current and prospective insureds and the 6
20	20	insureds' treating physicians; specifying requirements 7
21	21	for the content of such notice and the manner in which 8
22	22	it must be provided; specifying requirements for a 9
23	23	notice of medical necessity submitted by the treating 10
24	24	physician; authorizing insurers to provide cer tain 11
25	25	means for submitting the notice of medical necessity; 12
26	26	requiring the Financial Services Commission to adopt a 13
27	27	certain form by rule by a specified date; specifying a 14
28	28	coverage requirement and restrictions on coverage 15
29	29	modification by insurers receiving a notice of medical 16
30	30	necessity; providing construction and applicability; 17
31	31	requiring insurers to maintain a record of formulary 18
32	32	changes; requiring insurers to annually submit a 19
33	33	specified report to the Office of Insurance Regulation 20
34	34	by a specified date; requiri ng the office to annually 21
35	35	compile certain data and prepare a report, make the 22
36	36	report publicly accessible on its website, and submit 23
37	37	the report to the Governor and the Legislature by a 24
38	38	specified date; amending s. 627.6699, F.S.; requiring 25
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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	small employer carriers to comply with certain 26
52	52	requirements for prescription drug formulary changes; 27
53	53	amending s. 641.31, F.S.; providing an exception to 28
54	54	requirements relating to changes in a health 29
55	55	maintenance organization's group contract; requiring 30
56	56	health maintenance orga nizations to provide notice of 31
57	57	prescription drug formulary changes within a certain 32
58	58	timeframe to current and prospective subscribers and 33
59	59	the subscribers' treating physicians; specifying 34
60	60	requirements for the content of such notice and the 35
61	61	manner in which it must be provided; specifying 36
62	62	requirements for a notice of medical necessity 37
63	63	submitted by the treating physician; authorizing 38
64	64	health maintenance organizations to provide certain 39
65	65	means for submitting the notice of medical necessity; 40
66	66	requiring the commission to adopt a certain form by 41
67	67	rule by a specified date; specifying a coverage 42
68	68	requirement and restrictions on coverage modification 43
69	69	by health maintenance organizations receiving a notice 44
70	70	of medical necessity; providing construction and 45
71	71	applicability; requiri ng health maintenance 46
72	72	organizations to maintain a record of formulary 47
73	73	changes; requiring health maintenance organizations to 48
74	74	annually submit a specified report to the office by a 49
75	75	specified date; requiring the office to annually 50
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77	77	HB 1543 2024
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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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88	88	compile certain data and pre pare a report, make the 51
89	89	report publicly accessible on its website, and submit 52
90	90	the report to the Governor and the Legislature by a 53
91	91	specified date; providing applicability; providing a 54
92	92	declaration of important state interest; providing an 55
93	93	effective date. 56
94	94	57
95	95	Be It Enacted by the Legislature of the State of Florida: 58
96	96	59
97	97	Section 1. Section 627.42394, Florida Statutes, is created 60
98	98	to read: 61
99	99	627.42394 Health insurance policies; changes to 62
100	100	prescription drug formularies; requirements. — 63
101	101	(1) At least 60 days be fore the effective date of any 64
102	102	change to a prescription drug formulary during a policy year, an 65
103	103	insurer issuing individual or group health insurance policies in 66
104	104	the state shall notify: 67
105	105	(a) Current and prospective insureds of the change in the 68
106	106	formulary in a readily accessible format on the insurer's 69
107	107	website; and 70
108	108	(b) Any insured currently receiving coverage for a 71
109	109	prescription drug for which the formulary change modifies 72
110	110	coverage and the insured's treating physician. Such notification 73
111	111	must be sent electro nically and by first -class mail and must 74
112	112	include information on the specific drugs involved and a 75
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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	statement that the submission of a notice of medical necessity 76
126	126	by the insured's treating physician to the insurer at least 30 77
127	127	days before the effective date o f the formulary change will 78
128	128	result in continuation of coverage at the existing level. 79
129	129	(2) The notice provided by the treating physician to the 80
130	130	insurer must include a completed one -page form in which the 81
131	131	treating physician certifies to the insurer that th e 82
132	132	prescription drug for the insured is medically necessary as 83
133	133	defined in s. 627.732(2). The treating physician shall submit 84
134	134	the notice electronically or by first -class mail. The insurer 85
135	135	may provide the treating physician with access to an electronic 86
136	136	portal through which the treating physician may electronically 87
137	137	submit the notice. By January 1, 2025, the commission shall 88
138	138	adopt by rule a form for the notice. 89
139	139	(3) If the treating physician certifies to the insurer in 90
140	140	accordance with subsection (2) that the pr escription drug is 91
141	141	medically necessary for the insured, the insurer: 92
142	142	(a) Must authorize coverage for the prescribed drug until 93
143	143	the end of the policy year, based solely on the treating 94
144	144	physician's certification that the drug is medically necessary; 95
145	145	and 96
146	146	(b) May not modify the coverage related to the covered 97
147	147	drug during the policy year by: 98
148	148	1. Increasing the out -of-pocket costs for the covered 99
149	149	drug; 100
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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	2. Moving the covered drug to a more restrictive tier; 101
163	163	3. Denying an insured coverage of the drug for w hich the 102
164	164	insured has been previously approved for coverage by the 103
165	165	insurer; or 104
166	166	4. Limiting or reducing coverage of the drug in any other 105
167	167	way, including subjecting it to a new prior authorization or 106
168	168	step-therapy requirement. 107
169	169	(4) Subsections (1), (2), and (3) do not: 108
170	170	(a) Prohibit the addition of prescription drugs to the 109
171	171	list of drugs covered under the policy during the policy year. 110
172	172	(b) Apply to a grandfathered health plan as defined in s. 111
173	173	627.402 or to benefits specified in s. 627.6513(1) -(14). 112
174	174	(c) Alter or amend s. 465.025, which provides conditions 113
175	175	under which a pharmacist may substitute a generically equivalent 114
176	176	drug product for a brand name drug product. 115
177	177	(d) Alter or amend s. 465.0252, which provides conditions 116
178	178	under which a pharmacist may dispe nse a substitute biological 117
179	179	product for the prescribed biological product. 118
180	180	(e) Apply to a Medicaid managed care plan under part IV of 119
181	181	chapter 409. 120
182	182	(5) A health insurer shall maintain a record of any change 121
183	183	in its formulary during a calendar year. By Ma rch 1 of each 122
184	184	year, a health insurer shall submit to the office a report 123
185	185	delineating such changes made in the previous calendar year. The 124
186	186	annual report must include, at a minimum: 125
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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	(a) A list of all drugs removed from the formulary and the 126
200	200	reasons for the removal; 127
201	201	(b) A list of all drugs moved to a tier resulting in 128
202	202	additional out-of-pocket costs to insureds; 129
203	203	(c) The number of insureds notified by the insurer of a 130
204	204	change in the formulary; and 131
205	205	(d) The increased cost, by dollar amount, incurred by 132
206	206	insureds because of such change in the formulary. 133
207	207	(6) By May 1 of each year, the office shall: 134
208	208	(a) Compile the data in the annual reports submitted by 135
209	209	health insurers under subsection (5) and prepare a report 136
210	210	summarizing the data submitted; 137
211	211	(b) Make the report publicly accessible on its website; 138
212	212	and 139
213	213	(c) Submit the report to the Governor, the President of 140
214	214	the Senate, and the Speaker of the House of Representatives. 141
215	215	Section 2. Paragraph (e) of subsection (5) of section 142
216	216	627.6699, Florida Statutes, is a mended to read: 143
217	217	627.6699 Employee Health Care Access Act. — 144
218	218	(5) AVAILABILITY OF COVERAGE. — 145
219	219	(e) All health benefit plans issued under this section 146
220	220	must comply with the following conditions: 147
221	221	1. For employers who have fewer than two employees, a late 148
222	222	enrollee may be excluded from coverage for no longer than 24 149
223	223	months if he or she was not covered by creditable coverage 150
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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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234	234
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236	236	continually to a date not more than 63 days before the effective 151
237	237	date of his or her new coverage. 152
238	238	2. Any requirement used by a small em ployer carrier in 153
239	239	determining whether to provide coverage to a small employer 154
240	240	group, including requirements for minimum participation of 155
241	241	eligible employees and minimum employer contributions, must be 156
242	242	applied uniformly among all small employer groups having the 157
243	243	same number of eligible employees applying for coverage or 158
244	244	receiving coverage from the small employer carrier, except that 159
245	245	a small employer carrier that participates in, administers, or 160
246	246	issues health benefits pursuant to s. 381.0406 which do not 161
247	247	include a preexisting condition exclusion may require as a 162
248	248	condition of offering such benefits that the employer has had no 163
249	249	health insurance coverage for its employees for a period of at 164
250	250	least 6 months. A small employer carrier may vary application of 165
251	251	minimum participation requirements and minimum employer 166
252	252	contribution requirements only by the size of the small employer 167
253	253	group. 168
254	254	3. In applying minimum participation requirements with 169
255	255	respect to a small employer, a small employer carrier shall not 170
256	256	consider as an eligible employee employees or dependents who 171
257	257	have qualifying existing coverage in an employer -based group 172
258	258	insurance plan or an ERISA qualified self -insurance plan in 173
259	259	determining whether the applicable percentage of participation 174
260	260	is met. However, a small em ployer carrier may count eligible 175
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269	269	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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271	271
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273	273	employees and dependents who have coverage under another health 176
274	274	plan that is sponsored by that employer. 177
275	275	4. A small employer carrier shall not increase any 178
276	276	requirement for minimum employee participation or any 179
277	277	requirement for minimum employer contribution applicable to a 180
278	278	small employer at any time after the small employer has been 181
279	279	accepted for coverage, unless the employer size has changed, in 182
280	280	which case the small employer carrier may apply the requirements 183
281	281	that are applicable to the new group size. 184
282	282	5. If a small employer carrier offers coverage to a small 185
283	283	employer, it must offer coverage to all the small employer's 186
284	284	eligible employees and their dependents. A small employer 187
285	285	carrier may not offer coverage limited to certai n persons in a 188
286	286	group or to part of a group, except with respect to late 189
287	287	enrollees. 190
288	288	6. A small employer carrier may not modify any health 191
289	289	benefit plan issued to a small employer with respect to a small 192
290	290	employer or any eligible employee or dependent throug h riders, 193
291	291	endorsements, or otherwise to restrict or exclude coverage for 194
292	292	certain diseases or medical conditions otherwise covered by the 195
293	293	health benefit plan. 196
294	294	7. An initial enrollment period of at least 30 days must 197
295	295	be provided. An annual 30 -day open enrollment period must be 198
296	296	offered to each small employer's eligible employees and their 199
297	297	dependents. A small employer carrier must provide special 200
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306	306	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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308	308
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310	310	enrollment periods as required by s. 627.65615. 201
311	311	8. A small employer carrier shall comply with s. 627.42394 202
312	312	for any change to a prescription drug formulary. 203
313	313	Section 3. Subsection (36) of section 641.31, Florida 204
314	314	Statutes, is amended to read: 205
315	315	641.31 Health maintenance contracts. — 206
316	316	(36) Except as provided in paragraphs (a), (b), and (c), a 207
317	317	health maintenance organization may increase the copayment for 208
318	318	any benefit, or delete, amend, or limit any of the benefits to 209
319	319	which a subscriber is entitled under the group contract only, 210
320	320	upon written notice to the contract holder at least 45 days in 211
321	321	advance of the time of coverage renewal. The health maintenance 212
322	322	organization may amend the contract with the contract holder, 213
323	323	with such amendment to be effective immediately at the time of 214
324	324	coverage renewal. The written notice to the contract holder must 215
325	325	shall specifically identify any deletions, amendments, or 216
326	326	limitations to any of the benefits provided in the group 217
327	327	contract during the current contract period which will be 218
328	328	included in the group contract upon renewal. This subsection 219
329	329	does not apply to any incr eases in benefits. The 45 -day notice 220
330	330	requirement does shall not apply if benefits are amended, 221
331	331	deleted, or limited at the request of the contract holder. 222
332	332	(a) At least 60 days before the effective date of any 223
333	333	change to a prescription drug formulary during a contract year, 224
334	334	a health maintenance organization shall notify: 225
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343	343	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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347	347	1. Current and prospective subscribers of the change in 226
348	348	the formulary in a readily accessible format on the health 227
349	349	maintenance organization's website; and 228
350	350	2. Any subscriber currently rec eiving coverage for a 229
351	351	prescription drug for which the formulary change modifies 230
352	352	coverage and the subscriber's treating physician. Such 231
353	353	notification must be sent electronically and by first -class mail 232
354	354	and must include information on the specific drugs invol ved and 233
355	355	a statement that the submission of a notice of medical necessity 234
356	356	by the subscriber's treating physician to the health maintenance 235
357	357	organization at least 30 days before the effective date of the 236
358	358	formulary change will result in continuation of coverag e at the 237
359	359	existing level. 238
360	360	(b) The notice provided by the treating physician to the 239
361	361	health maintenance organization must include a completed one -240
362	362	page form in which the treating physician certifies to the 241
363	363	health maintenance organization that the prescriptio n drug for 242
364	364	the subscriber is medically necessary as defined in s. 243
365	365	627.732(2). The treating physician shall submit the notice 244
366	366	electronically or by first -class mail. The health maintenance 245
367	367	organization may provide the treating physician with access to 246
368	368	an electronic portal through which the treating physician may 247
369	369	electronically submit the notice. By January 1, 2025, the 248
370	370	commission shall adopt by rule a form for the notice. 249
371	371	(c) If the treating physician certifies to the health 250
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380	380	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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384	384	maintenance organization in acco rdance with paragraph (b) that 251
385	385	the prescription drug is medically necessary for the subscriber, 252
386	386	the health maintenance organization: 253
387	387	1. Must authorize coverage for the prescribed drug until 254
388	388	the end of the contract year, based solely on the treating 255
389	389	physician's certification that the drug is medically necessary; 256
390	390	and 257
391	391	2. May not modify the coverage related to the covered drug 258
392	392	during the contract year by: 259
393	393	a. Increasing the out -of-pocket costs for the covered 260
394	394	drug; 261
395	395	b. Moving the covered drug to a more re strictive tier; 262
396	396	c. Denying a subscriber coverage of the drug for which the 263
397	397	subscriber has been previously approved for coverage by the 264
398	398	health maintenance organization; or 265
399	399	d. Limiting or reducing coverage of the drug in any other 266
400	400	way, including subjecti ng it to a new prior authorization or 267
401	401	step-therapy requirement. 268
402	402	(d) Paragraphs (a), (b), and (c) do not: 269
403	403	1. Prohibit the addition of prescription drugs to the list 270
404	404	of drugs covered under the contract during the contract year. 271
405	405	2. Apply to a grandfathe red health plan as defined in s. 272
406	406	627.402 or to benefits specified in s. 627.6513(1) -(14). 273
407	407	3. Alter or amend s. 465.025, which provides conditions 274
408	408	under which a pharmacist may substitute a generically equivalent 275
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417	417	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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421	421	drug product for a brand name drug product. 276
422	422	4. Alter or amend s. 465.0252, which provides conditions 277
423	423	under which a pharmacist may dispense a substitute biological 278
424	424	product for the prescribed biological product. 279
425	425	5. Apply to a Medicaid managed care plan under part IV of 280
426	426	chapter 409. 281
427	427	(e) A health maintenance organization shall maintain a 282
428	428	record of any change in its formulary during a calendar year. By 283
429	429	March 1 of each year, a health maintenance organization shall 284
430	430	submit to the office a report delineating such changes made in 285
431	431	the previous calendar y ear. The annual report must include, at a 286
432	432	minimum: 287
433	433	1. A list of all drugs removed from the formulary and the 288
434	434	reasons for the removal; 289
435	435	2. A list of all drugs moved to a tier resulting in 290
436	436	additional out-of-pocket costs to subscribers; 291
437	437	3. The number of subscribers notified by the health 292
438	438	maintenance organization of a change in the formulary; and 293
439	439	4. The increased cost, by dollar amount, incurred by 294
440	440	subscribers because of such change in the formulary. 295
441	441	(f) By May 1 of each year, the office shall: 296
442	442	1. Compile the data in such annual reports submitted by 297
443	443	health maintenance organizations and prepare a report 298
444	444	summarizing the data submitted; 299
445	445	2. Make the report publicly accessible on its website; and 300
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454	454	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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458	458	3. Submit the report to the Governor, the President of t he 301
459	459	Senate, and the Speaker of the House of Representatives. 302
460	460	Section 4. This act applies to health insurance policies, 303
461	461	health benefit plans, and health maintenance contracts entered 304
462	462	into or renewed on or after January 1, 2025. 305
463	463	Section 5. The Legislature finds that this act fulfills an 306
464	464	important state interest. 307
465	465	Section 6. This act shall take effect January 1, 2025. 308