Florida 2025 Regular Session

Florida House Bill H0899 Compare Versions

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

Old	New	Differences
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3	3	HB 899 2025
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7	7	CODING: Words stricken are deletions; words underlined are additions.
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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
11	11
12	12
13	13
14	14	A bill to be entitled 1
15	15	An act relating to insurer disclosures on prescription 2
16	16	drug coverage; creating s. 627.42394, F.S.; requiring 3
17	17	individual and group health insurers to provide notice 4
18	18	of prescription drug formulary changes within a 5
19	19	certain timeframe to current and prospective insureds 6
20	20	and the insureds' treating physicians; specifying 7
21	21	requirements for the content of such notice and the 8
22	22	manner in which it must be provided; specifying 9
23	23	requirements for a notice of medical necessity 10
24	24	submitted by the treating physician; authorizing 11
25	25	insurers to provide certain means for submitting the 12
26	26	notice of medical necessity; requiring the Financial 13
27	27	Services Commission to adopt a certain form by rule by 14
28	28	a specified date; specifying a coverage requirement 15
29	29	and restrictions on coverage modification b y insurers 16
30	30	receiving a notice of medical necessity; providing 17
31	31	construction and applicability; requiring insurers to 18
32	32	maintain a record of formulary changes; requiring 19
33	33	insurers to annually submit a specified report to the 20
34	34	Office of Insurance Regulation by a specified date; 21
35	35	requiring the office to annually compile certain data 22
36	36	and prepare a report, make the report publicly 23
37	37	accessible on its website, and submit the report to 24
38	38	the Governor and the Legislature by a specified date; 25
39	39
40	40	HB 899 2025
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45	45	hb899-00
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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
48	48
49	49
50	50
51	51	creating s. 627.6383, F.S.; defin ing the term "cost-26
52	52	sharing requirement"; requiring specified individual 27
53	53	health insurers and their pharmacy benefit managers to 28
54	54	apply payments for prescription drugs by or on behalf 29
55	55	of insureds toward the total contributions of the 30
56	56	insureds' cost-sharing requirements under certain 31
57	57	circumstances; providing construction; requiring 32
58	58	specified individual health insurers to maintain 33
59	59	records of certain third -party payments for 34
60	60	prescription drugs; providing reporting requirements; 35
61	61	providing requirements for the repo rts; providing 36
62	62	applicability; amending s. 627.6385, F.S.; providing 37
63	63	disclosure requirements; providing applicability; 38
64	64	amending s. 627.64741, F.S.; requiring specified 39
65	65	contracts to require pharmacy benefit managers to 40
66	66	apply payments by or on behalf of insur eds toward the 41
67	67	insureds' total contributions to cost -sharing 42
68	68	requirements; providing applicability; providing 43
69	69	disclosure requirements; creating s. 627.65715, F.S.; 44
70	70	defining the term "cost -sharing requirement"; 45
71	71	requiring specified group health insurers and their 46
72	72	pharmacy benefit managers to apply payments for 47
73	73	prescription drugs by or on behalf of insureds toward 48
74	74	the total contributions of the insureds' cost -sharing 49
75	75	requirements under certain circumstances; providing 50
76	76
77	77	HB 899 2025
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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
85	85
86	86
87	87
88	88	construction; providing disclosure require ments; 51
89	89	requiring specified group health insurers to maintain 52
90	90	records of certain third -party payments for 53
91	91	prescription drugs; providing reporting requirements; 54
92	92	providing requirements for the reports; providing 55
93	93	applicability; amending s. 627.6572, F.S.; requ iring 56
94	94	specified contracts to require pharmacy benefit 57
95	95	managers to apply payments by or on behalf of insureds 58
96	96	toward the insureds' total contributions to cost -59
97	97	sharing requirements; providing applicability; 60
98	98	providing disclosure requirements; amending s. 61
99	99	627.6699, F.S.; requiring small employer carriers to 62
100	100	comply with certain requirements for prescription drug 63
101	101	formulary changes; amending s. 641.31, F.S.; providing 64
102	102	an exception to requirements relating to changes in a 65
103	103	health maintenance organization's group con tract; 66
104	104	requiring health maintenance organizations to provide 67
105	105	notice of prescription drug formulary changes within a 68
106	106	certain timeframe to current and prospective 69
107	107	subscribers and the subscribers' treating physicians; 70
108	108	specifying requirements for the content o f such notice 71
109	109	and the manner in which it must be provided; 72
110	110	specifying requirements for a notice of medical 73
111	111	necessity submitted by the treating physician; 74
112	112	authorizing health maintenance organizations to 75
113	113
114	114	HB 899 2025
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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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123	123
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125	125	provide certain means for submitting the notice of 76
126	126	medical necessity; requiring the commission to adopt a 77
127	127	certain form by rule by a specified date; specifying a 78
128	128	coverage requirement and restrictions on coverage 79
129	129	modification by health maintenance organizations 80
130	130	receiving a notice of medical necessity; providing 81
131	131	construction and applicability; requiring health 82
132	132	maintenance organizations to maintain a record of 83
133	133	formulary changes; requiring health maintenance 84
134	134	organizations to annually submit a specified report to 85
135	135	the office by a specified date; requiring the office 86
136	136	to annually compile certain data and prepare a report, 87
137	137	make the report publicly accessible on its website, 88
138	138	and submit the report to the Governor and the 89
139	139	Legislature by a specified date; defining the term 90
140	140	"cost-sharing requirement"; requiring specified heal th 91
141	141	maintenance organizations and their pharmacy benefit 92
142	142	managers to apply payments for prescription drugs by 93
143	143	or on behalf of subscribers toward the total 94
144	144	contributions of the subscribers' cost -sharing 95
145	145	requirements under certain circumstances; providing 96
146	146	construction; providing disclosure requirements; 97
147	147	requiring specified health maintenance organizations 98
148	148	to maintain records of certain third -party payments 99
149	149	for prescription drugs; providing reporting 100
150	150
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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
159	159
160	160
161	161
162	162	requirements; providing requirements for the reports; 101
163	163	providing applicability; amending s. 641.314, F.S.; 102
164	164	requiring specified contracts to require pharmacy 103
165	165	benefit managers to apply payments by or on behalf of 104
166	166	subscribers toward the subscribers' total 105
167	167	contributions to cost -sharing requirements; providing 106
168	168	applicability; providing disclosure requirements; 107
169	169	amending s. 409.967, F.S.; conforming a cross -108
170	170	reference; amending s. 641.185, F.S.; conforming a 109
171	171	provision to changes made by the act; providing 110
172	172	applicability; providing a declaration of important 111
173	173	state interest; prov iding an effective date. 112
174	174	113
175	175	Be It Enacted by the Legislature of the State of Florida: 114
176	176	115
177	177	Section 1. Section 627.42394, Florida Statutes, is created 116
178	178	to read: 117
179	179	627.42394 Health insurance policies; changes to 118
180	180	prescription drug formularies; requirements. — 119
181	181	(1) At least 60 days before the effective date of any 120
182	182	change to a prescription drug formulary during a policy year, an 121
183	183	insurer issuing individual or group health insurance policies in 122
184	184	the state shall notify: 123
185	185	(a) Current and prospective insureds of the change in the 124
186	186	formulary in a readily accessible format on the insurer's 125
187	187
188	188	HB 899 2025
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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
196	196
197	197
198	198
199	199	website; and 126
200	200	(b) Any insured currently receiving coverage for a 127
201	201	prescription drug for which the formulary change modifies 128
202	202	coverage and the insured's treating physician. Such notific ation 129
203	203	must be sent electronically and by first -class mail and must 130
204	204	include information on the specific drugs involved and a 131
205	205	statement that the submission of a notice of medical necessity 132
206	206	by the insured's treating physician to the insurer at least 30 133
207	207	days before the effective date of the formulary change will 134
208	208	result in continuation of coverage at the existing level. 135
209	209	(2) The notice provided by the treating physician to the 136
210	210	insurer must include a completed one -page form in which the 137
211	211	treating physician certif ies to the insurer that the 138
212	212	prescription drug for the insured is medically necessary as 139
213	213	defined in s. 627.732(2). The treating physician shall submit 140
214	214	the notice electronically or by first -class mail. The insurer 141
215	215	may provide the treating physician with acce ss to an electronic 142
216	216	portal through which the treating physician may electronically 143
217	217	submit the notice. By January 1, 2026, the commission shall 144
218	218	adopt by rule a form for the notice. 145
219	219	(3) If the treating physician certifies to the insurer in 146
220	220	accordance with subsection (2) that the prescription drug is 147
221	221	medically necessary for the insured, the insurer: 148
222	222	(a) Must authorize coverage for the prescribed drug until 149
223	223	the end of the policy year, based solely on the treating 150
224	224
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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
233	233
234	234
235	235
236	236	physician's certification that the drug is m edically necessary; 151
237	237	and 152
238	238	(b) May not modify the coverage related to the covered 153
239	239	drug during the policy year by: 154
240	240	1. Increasing the out -of-pocket costs for the covered 155
241	241	drug; 156
242	242	2. Moving the covered drug to a more restrictive tier; 157
243	243	3. Denying an insured coverage of the drug for which the 158
244	244	insured has been previously approved for coverage by the 159
245	245	insurer; or 160
246	246	4. Limiting or reducing coverage of the drug in any other 161
247	247	way, including subjecting it to a new prior authorization or 162
248	248	step-therapy requirement. 163
249	249	(4) Subsections (1), (2), and (3) do not: 164
250	250	(a) Prohibit the addition of prescription drugs to the 165
251	251	list of drugs covered under the policy during the policy year. 166
252	252	(b) Apply to a grandfathered health plan as defined in s. 167
253	253	627.402 or to benefits specified in s . 627.6513(1)-(14). 168
254	254	(c) Alter or amend s. 465.025, which provides conditions 169
255	255	under which a pharmacist may substitute a generically equivalent 170
256	256	drug product for a brand name drug product. 171
257	257	(d) Alter or amend s. 465.0252, which provides conditions 172
258	258	under which a pharmacist may dispense a substitute biological 173
259	259	product for the prescribed biological product. 174
260	260	(e) Apply to a Medicaid managed care plan under part IV of 175
261	261
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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
272	272
273	273	chapter 409. 176
274	274	(5) A health insurer shall maintain a record of any change 177
275	275	in its formulary dur ing a calendar year. By March 1 of each 178
276	276	year, a health insurer shall submit to the office a report 179
277	277	delineating such changes made in the previous calendar year. The 180
278	278	annual report must include, at a minimum: 181
279	279	(a) A list of all drugs removed from the formula ry, along 182
280	280	with the date of the removal and the reasons for the removal. 183
281	281	(b) A list of all drugs moved to a tier resulting in 184
282	282	additional out-of-pocket costs to insureds. 185
283	283	(c) The number of insureds impacted by a change in the 186
284	284	formulary. 187
285	285	(d) The number of insureds notified by the insurer of a 188
286	286	change in the formulary. 189
287	287	(e) The increased cost, by dollar amount, incurred by 190
288	288	insureds because of such change in the formulary. 191
289	289	(6) By May 1 of each year, the office shall: 192
290	290	(a) Compile the data in the annual reports submitted by 193
291	291	health insurers under subsection (5) and prepare a report 194
292	292	summarizing the data submitted. 195
293	293	(b) Make the report publicly accessible on its website. 196
294	294	(c) Submit the report to the Governor, the President of 197
295	295	the Senate, and the Speaker o f the House of Representatives. 198
296	296	Section 2. Section 627.6383, Florida Statutes, is created 199
297	297	to read: 200
298	298
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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
309	309
310	310	627.6383 Cost-sharing requirements. — 201
311	311	(1) As used in this section, the term "cost -sharing 202
312	312	requirement" means a dollar limit, a deductible, a copayment , 203
313	313	coinsurance, or any other out -of-pocket expense imposed on an 204
314	314	insured, including, but not limited to, the annual limitation on 205
315	315	cost sharing subject to 42 U.S.C. s. 18022. 206
316	316	(2)(a) Each health insurer issuing, delivering, or 207
317	317	renewing a policy in this stat e which provides prescription drug 208
318	318	coverage, or each pharmacy benefit manager on behalf of such 209
319	319	health insurer, shall apply any amount paid for a prescription 210
320	320	drug by an insured or by another person on behalf of the insured 211
321	321	toward the insured's total contr ibution to any cost-sharing 212
322	322	requirement, if the prescription drug: 213
323	323	1. Does not have a generic equivalent; or 214
324	324	2. Has a generic equivalent and the insured has obtained 215
325	325	authorization for the prescription drug through any of the 216
326	326	following: 217
327	327	a. Prior authorization from the health insurer or pharmacy 218
328	328	benefit manager. 219
329	329	b. A step-therapy protocol. 220
330	330	c. The exception or appeal process of the health insurer 221
331	331	or pharmacy benefit manager. 222
332	332	(b) The amount paid by or on behalf of the insured which 223
333	333	is applied toward the insured's total contribution to any cost -224
334	334	sharing requirement under paragraph (a) includes, but is not 225
335	335
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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
344	344
345	345
346	346
347	347	limited to, any payment with or any discount through financial 226
348	348	assistance, a manufacturer copay card, a product voucher, or any 227
349	349	other reduction in ou t-of-pocket expenses made by or on behalf 228
350	350	of the insured for a prescription drug. 229
351	351	(c)1. Each health insurer issuing, delivering, or renewing 230
352	352	a policy in this state which provides prescription drug 231
353	353	coverage, regardless of whether the prescription drug benefits 232
354	354	are administered or managed by the insurer or by a pharmacy 233
355	355	benefit manager on behalf of the insurer, shall maintain a 234
356	356	record of any third-party payments, made or remitted on behalf 235
357	357	of an insured, for prescription drugs, which are not applied to 236
358	358	the insured's out-of-pocket obligations, including, but not 237
359	359	limited to, deductibles, copayments, or coinsurance. 238
360	360	2. By March 1 of each year, each health insurer issuing, 239
361	361	delivering, or renewing a policy in this state which provides 240
362	362	prescription drug cover age, regardless of whether the 241
363	363	prescription drug benefits are administered or managed by the 242
364	364	insurer or by a pharmacy benefit manager on behalf of the 243
365	365	insurer, shall submit to the office a report delineating third -244
366	366	party payments, as described in subparagra ph 1., which were 245
367	367	received in the previous calendar year. The annual report must 246
368	368	include, at a minimum: 247
369	369	a. A list of all payments received by the health insurer, 248
370	370	as described in subparagraph 1., made or remitted by a third 249
371	371	party, which must include: 250
372	372
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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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383	383
384	384	(I) The date each payment was made. 251
385	385	(II) The prescription drug for which the payment was made. 252
386	386	(III) The reason that the payment was not applied to the 253
387	387	insured's out-of-pocket obligations. 254
388	388	b. The total amount of payments received by the health 255
389	389	insurer which were not applied to an insured's out -of-pocket 256
390	390	maximum. 257
391	391	c. The total number of insureds for which a payment was 258
392	392	made which was not applied to an out -of-pocket maximum. 259
393	393	d. Whether such payments were returned to the third party 260
394	394	who submitted the pa yment. 261
395	395	e. The total amount of payments which were not returned to 262
396	396	the third party who submitted the payment. 263
397	397	(3) This section applies to any health insurance policy 264
398	398	issued, delivered, or renewed in this state on or after January 265
399	399	1, 2026. 266
400	400	Section 3. Subsections (2) and (3) of section 627.6385, 267
401	401	Florida Statutes, are renumbered as subsections (3) and (4), 268
402	402	respectively, present subsection (2) of that section is amended, 269
403	403	and a new subsection (2) is added to that section, to read: 270
404	404	627.6385 Disclosures t o policyholders; calculations of 271
405	405	cost sharing.— 272
406	406	(2) Each health insurer issuing, delivering, or renewing a 273
407	407	policy in this state which provides prescription drug coverage, 274
408	408	regardless of whether the prescription drug benefits are 275
409	409
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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	administered or managed by the health insurer or by a pharmacy 276
422	422	benefit manager on behalf of the health insurer, shall disclose 277
423	423	on its website that any amount paid by a policyholder or by 278
424	424	another person on behalf of the policyholder must be applied 279
425	425	toward the policyholder's total co ntribution to any cost -sharing 280
426	426	requirement pursuant to s. 627.6383. This subsection applies to 281
427	427	any policy issued, delivered, or renewed in this state on or 282
428	428	after January 1, 2026. 283
429	429	(3)(2) Each health insurer shall include in every policy 284
430	430	delivered or issued for delivery to any person in this the state 285
431	431	or in materials provided as required by s. 627.64725 a notice 286
432	432	that the information required by this section is available 287
433	433	electronically and the website address of the website where the 288
434	434	information can be acces sed. In addition, each health insurer 289
435	435	issuing, delivering, or renewing a policy in this state which 290
436	436	provides prescription drug coverage, regardless of whether the 291
437	437	prescription drug benefits are administered or managed by the 292
438	438	health insurer or by a pharmacy benefit manager on behalf of the 293
439	439	health insurer, shall disclose in every policy that is issued, 294
440	440	delivered, or renewed to any person in this state on or after 295
441	441	January 1, 2026, that any amount paid by a policyholder or by 296
442	442	another person on behalf of the pol icyholder must be applied 297
443	443	toward the policyholder's total contribution to any cost -sharing 298
444	444	requirement pursuant to s. 627.6383. 299
445	445	Section 4. Paragraph (c) is added to subsection (2) of 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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457	457
458	458	section 627.64741, Florida Statutes, to read: 301
459	459	627.64741 Pharmacy be nefit manager contracts. — 302
460	460	(2) In addition to the requirements of part VII of chapter 303
461	461	626, a contract between a health insurer and a pharmacy benefit 304
462	462	manager must require that the pharmacy benefit manager: 305
463	463	(c)1. Apply any amount paid by an insured or by another 306
464	464	person on behalf of the insured toward the insured's total 307
465	465	contribution to any cost -sharing requirement pursuant to s. 308
466	466	627.6383. This subparagraph applies to any insured whose 309
467	467	insurance policy is issued, delivered, or renewed in this state 310
468	468	on or after January 1, 2026. 311
469	469	2. Disclose to every insured whose insurance policy is 312
470	470	issued, delivered, or renewed in this state on or after January 313
471	471	1, 2026, that the pharmacy benefit manager shall apply any 314
472	472	amount paid by the insured or by another person on beh alf of the 315
473	473	insured toward the insured's total contribution to any cost -316
474	474	sharing requirement pursuant to s. 627.6383. 317
475	475	Section 5. Section 627.65715, Florida Statutes, is created 318
476	476	to read: 319
477	477	627.65715 Cost-sharing requirements. — 320
478	478	(1) As used in this sectio n, the term "cost-sharing 321
479	479	requirement" means a dollar limit, a deductible, a copayment, 322
480	480	coinsurance, or any other out -of-pocket expense imposed on an 323
481	481	insured, including, but not limited to, the annual limitation on 324
482	482	cost sharing subject to 42 U.S.C. s. 1802 2. 325
483	483
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491	491	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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495	495	(2)(a) Each insurer issuing, delivering, or renewing a 326
496	496	policy in this state which provides prescription drug coverage, 327
497	497	or each pharmacy benefit manager on behalf of such insurer, 328
498	498	shall apply any amount paid for a prescription drug by an 329
499	499	insured or by another person on behalf of the insured toward the 330
500	500	insured's total contribution to any cost -sharing requirement, if 331
501	501	the prescription drug: 332
502	502	1. Does not have a generic equivalent; or 333
503	503	2. Has a generic equivalent and the insured has obtained 334
504	504	authorization for the prescription drug through any of the 335
505	505	following: 336
506	506	a. Prior authorization from the health insurer or pharmacy 337
507	507	benefit manager. 338
508	508	b. A step-therapy protocol. 339
509	509	c. The exception or appeal process of the health insurer 340
510	510	or pharmacy benefit manager. 341
511	511	(b) The amount paid by or on behalf of the insured which 342
512	512	is applied toward the insured's total contribution to any cost -343
513	513	sharing requirement under paragraph (a) includes, but is not 344
514	514	limited to, any payment with or any discount through financial 345
515	515	assistance, a manufacturer copay card, a product voucher, or any 346
516	516	other reduction in out -of-pocket expenses made by or on behalf 347
517	517	of the insured for a prescription drug. 348
518	518	(3)(a) Each insurer issuing, delivering, or renewing a 349
519	519	policy in this state which provides prescript ion drug coverage, 350
520	520
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528	528	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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532	532	regardless of whether the prescription drug benefits are 351
533	533	administered or managed by the insurer or by a pharmacy benefit 352
534	534	manager on behalf of the insurer, shall disclose on its website 353
535	535	and in every policy issued, delivered, or renewed in this state 354
536	536	on or after January 1, 2026, that any amount paid by an insured 355
537	537	or by another person on behalf of the insured must be applied 356
538	538	toward the insured's total contribution to any cost -sharing 357
539	539	requirement. 358
540	540	(b)1. Each health insurer issuing, delivering, or renewing 359
541	541	a policy in this state which provides prescription drug 360
542	542	coverage, regardless of whether the prescription drug benefits 361
543	543	are administered or managed by the insurer or by a pharmacy 362
544	544	benefit manager on behalf of the insurer, shall maint ain a 363
545	545	record of any third-party payments, made or remitted on behalf 364
546	546	of an insured, for prescription drugs, which are not applied to 365
547	547	the insured's out-of-pocket obligations, including, but not 366
548	548	limited to, deductibles, copayments, or coinsurance. 367
549	549	2. By March 1 of each year, each health insurer issuing, 368
550	550	delivering, or renewing a policy in this state which provides 369
551	551	prescription drug coverage, regardless of whether the 370
552	552	prescription drug benefits are administered or managed by the 371
553	553	insurer or by a pharmacy bene fit manager on behalf of the 372
554	554	insurer, shall submit to the office a report delineating third -373
555	555	party payments, as described in subparagraph 1., which were 374
556	556	received in the previous calendar year. The annual report must 375
557	557
558	558	HB 899 2025
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560	560
561	561
562	562	CODING: Words stricken are deletions; words underlined are additions.
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565	565	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
566	566
567	567
568	568
569	569	include, at a minimum: 376
570	570	a. A list of all payments received by the health insurer, 377
571	571	as described in subparagraph 1., made or remitted by a third 378
572	572	party, which must include: 379
573	573	(I) The date each payment was made. 380
574	574	(II) The prescription drug for which the payment was made. 381
575	575	(III) The reason that the payment was not applied to the 382
576	576	insured's out-of-pocket obligations. 383
577	577	b. The total amount of payments received by the health 384
578	578	insurer which were not applied to an insured's out -of-pocket 385
579	579	maximum. 386
580	580	c. The total number of insureds for which a payment was 387
581	581	made which was not applied to an out -of-pocket maximum. 388
582	582	d. Whether such payments were returned to the third party 389
583	583	who submitted the payment. 390
584	584	e. The total amount of payments which were not returned to 391
585	585	the third party who submitted the payment. 392
586	586	(4) This section applies to any group health insurance 393
587	587	policy issued, delivered, or renewed in this state on or after 394
588	588	January 1, 2026. 395
589	589	Section 6. Paragraph (c) is added to subsection (2) of 396
590	590	section 627.6572, Florida Statutes, to read: 397
591	591	627.6572 Pharmacy bene fit manager contracts. — 398
592	592	(2) In addition to the requirements of part VII of chapter 399
593	593	626, a contract between a health insurer and a pharmacy benefit 400
594	594
595	595	HB 899 2025
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597	597
598	598
599	599	CODING: Words stricken are deletions; words underlined are additions.
600	600	hb899-00
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602	602	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
603	603
604	604
605	605
606	606	manager must require that the pharmacy benefit manager: 401
607	607	(c)1. Apply any amount paid by an insured or by a nother 402
608	608	person on behalf of the insured toward the insured's total 403
609	609	contribution to any cost -sharing requirement pursuant to s. 404
610	610	627.65715. This subparagraph applies to any insured whose 405
611	611	insurance policy is issued, delivered, or renewed in this state 406
612	612	on or after January 1, 2026. 407
613	613	2. Disclose to every insured whose insurance policy is 408
614	614	issued, delivered, or renewed in this state on or after January 409
615	615	1, 2026, that the pharmacy benefit manager shall apply any 410
616	616	amount paid by the insured or by another person on beha lf of the 411
617	617	insured toward the insured's total contribution to any cost -412
618	618	sharing requirement pursuant to s. 627.65715. 413
619	619	Section 7. Paragraph (e) of subsection (5) of section 414
620	620	627.6699, Florida Statutes, is amended to read: 415
621	621	627.6699 Employee Health Care Ac cess Act.— 416
622	622	(5) AVAILABILITY OF COVERAGE. — 417
623	623	(e) All health benefit plans issued under this section 418
624	624	must comply with the following conditions: 419
625	625	1. For employers who have fewer than two employees, a late 420
626	626	enrollee may be excluded from coverage for no longe r than 24 421
627	627	months if he or she was not covered by creditable coverage 422
628	628	continually to a date not more than 63 days before the effective 423
629	629	date of his or her new coverage. 424
630	630	2. Any requirement used by a small employer carrier in 425
631	631
632	632	HB 899 2025
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634	634
635	635
636	636	CODING: Words stricken are deletions; words underlined are additions.
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639	639	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
640	640
641	641
642	642
643	643	determining whether to provide c overage to a small employer 426
644	644	group, including requirements for minimum participation of 427
645	645	eligible employees and minimum employer contributions, must be 428
646	646	applied uniformly among all small employer groups having the 429
647	647	same number of eligible employees applying fo r coverage or 430
648	648	receiving coverage from the small employer carrier, except that 431
649	649	a small employer carrier that participates in, administers, or 432
650	650	issues health benefits pursuant to s. 381.0406 which do not 433
651	651	include a preexisting condition exclusion may require a s a 434
652	652	condition of offering such benefits that the employer has had no 435
653	653	health insurance coverage for its employees for a period of at 436
654	654	least 6 months. A small employer carrier may vary application of 437
655	655	minimum participation requirements and minimum employer 438
656	656	contribution requirements only by the size of the small employer 439
657	657	group. 440
658	658	3. In applying minimum participation requirements with 441
659	659	respect to a small employer, a small employer carrier may shall 442
660	660	not consider as an eligible employee employees or dependents who 443
661	661	have qualifying existing coverage in an employer -based group 444
662	662	insurance plan or an ERISA qualified self -insurance plan in 445
663	663	determining whether the applicable percentage of participation 446
664	664	is met. However, a small employer carrier may count eligible 447
665	665	employees and dependents who have coverage under another health 448
666	666	plan that is sponsored by that employer. 449
667	667	4. A small employer carrier may shall not increase any 450
668	668
669	669	HB 899 2025
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671	671
672	672
673	673	CODING: Words stricken are deletions; words underlined are additions.
674	674	hb899-00
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676	676	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
677	677
678	678
679	679
680	680	requirement for minimum employee participation or any 451
681	681	requirement for minimum employer contribution applic able to a 452
682	682	small employer at any time after the small employer has been 453
683	683	accepted for coverage, unless the employer size has changed, in 454
684	684	which case the small employer carrier may apply the requirements 455
685	685	that are applicable to the new group size. 456
686	686	5. If a small employer carrier offers coverage to a small 457
687	687	employer, it must offer coverage to all the small employer's 458
688	688	eligible employees and their dependents. A small employer 459
689	689	carrier may not offer coverage limited to certain persons in a 460
690	690	group or to part of a group , except with respect to late 461
691	691	enrollees. 462
692	692	6. A small employer carrier may not modify any health 463
693	693	benefit plan issued to a small employer with respect to a small 464
694	694	employer or any eligible employee or dependent through riders, 465
695	695	endorsements, or otherwise to re strict or exclude coverage for 466
696	696	certain diseases or medical conditions otherwise covered by the 467
697	697	health benefit plan. 468
698	698	7. An initial enrollment period of at least 30 days must 469
699	699	be provided. An annual 30 -day open enrollment period must be 470
700	700	offered to each smal l employer's eligible employees and their 471
701	701	dependents. A small employer carrier must provide special 472
702	702	enrollment periods as required by s. 627.65615. 473
703	703	8. A small employer carrier shall comply with s. 627.65715 474
704	704	for any change to a prescription drug formulary . 475
705	705
706	706	HB 899 2025
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708	708
709	709
710	710	CODING: Words stricken are deletions; words underlined are additions.
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713	713	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
714	714
715	715
716	716
717	717	Section 8. Subsection (36) of section 641.31, Florida 476
718	718	Statutes, is amended, and subsection (48) is added to that 477
719	719	section, to read: 478
720	720	641.31 Health maintenance contracts. — 479
721	721	(36) Except as provided in paragraphs (a), (b), and (c), a 480
722	722	health maintenance organization may increase the copayment for 481
723	723	any benefit, or delete, amend, or limit any of the benefits to 482
724	724	which a subscriber is entitled under the group contract only, 483
725	725	upon written notice to the contract holder at least 45 days in 484
726	726	advance of the time of coverage renewal. The health maintenance 485
727	727	organization may amend the contract with the contract holder, 486
728	728	with such amendment to be effective immediately at the time of 487
729	729	coverage renewal. The written notice to the contract holder must 488
730	730	shall specifically identify any deletions, amendments, or 489
731	731	limitations to any of the benefits provided in the group 490
732	732	contract during the current contract period which will be 491
733	733	included in the group contract upon renewal. This subsection 492
734	734	does not apply to any incr eases in benefits. The 45 -day notice 493
735	735	requirement does shall not apply if benefits are amended, 494
736	736	deleted, or limited at the request of the contract holder. 495
737	737	(a) At least 60 days before the effective date of any 496
738	738	change to a prescription drug formulary during a contract year, 497
739	739	a health maintenance organization shall notify: 498
740	740	1. Current and prospective subscribers of the change in 499
741	741	the formulary in a readily accessible format on the health 500
742	742
743	743	HB 899 2025
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745	745
746	746
747	747	CODING: Words stricken are deletions; words underlined are additions.
748	748	hb899-00
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750	750	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
751	751
752	752
753	753
754	754	maintenance organization's website; and 501
755	755	2. Any subscriber currently rec eiving coverage for a 502
756	756	prescription drug for which the formulary change modifies 503
757	757	coverage and the subscriber's treating physician. Such 504
758	758	notification must be sent electronically and by first -class mail 505
759	759	and must include information on the specific drugs invol ved and 506
760	760	a statement that the submission of a notice of medical necessity 507
761	761	by the subscriber's treating physician to the health maintenance 508
762	762	organization at least 30 days before the effective date of the 509
763	763	formulary change will result in continuation of coverag e at the 510
764	764	existing level. 511
765	765	(b) The notice provided by the treating physician to the 512
766	766	health maintenance organization must include a completed one -513
767	767	page form in which the treating physician certifies to the 514
768	768	health maintenance organization that the prescriptio n drug for 515
769	769	the subscriber is medically necessary as defined in s. 516
770	770	627.732(2). The treating physician shall submit the notice 517
771	771	electronically or by first -class mail. The health maintenance 518
772	772	organization may provide the treating physician with access to 519
773	773	an electronic portal through which the treating physician may 520
774	774	electronically submit the notice. By January 1, 2026, the 521
775	775	commission shall adopt by rule a form for the notice. 522
776	776	(c) If the treating physician certifies to the health 523
777	777	maintenance organization in acco rdance with paragraph (b) that 524
778	778	the prescription drug is medically necessary for the subscriber, 525
779	779
780	780	HB 899 2025
781	781
782	782
783	783
784	784	CODING: Words stricken are deletions; words underlined are additions.
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787	787	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
788	788
789	789
790	790
791	791	the health maintenance organization: 526
792	792	1. Must authorize coverage for the prescribed drug until 527
793	793	the end of the contract year, based solely on the treating 528
794	794	physician's certification that the drug is medically necessary; 529
795	795	and 530
796	796	2. May not modify the coverage related to the covered drug 531
797	797	during the contract year by: 532
798	798	a. Increasing the out -of-pocket costs for the covered 533
799	799	drug; 534
800	800	b. Moving the covered drug to a more re strictive tier; 535
801	801	c. Denying a subscriber coverage of the drug for which the 536
802	802	subscriber has been previously approved for coverage by the 537
803	803	health maintenance organization; or 538
804	804	d. Limiting or reducing coverage of the drug in any other 539
805	805	way, including subjecti ng it to a new prior authorization or 540
806	806	step-therapy requirement. 541
807	807	(d) Paragraphs (a), (b), and (c) do not: 542
808	808	1. Prohibit the addition of prescription drugs to the list 543
809	809	of drugs covered under the contract during the contract year. 544
810	810	2. Apply to a grandfathe red health plan as defined in s. 545
811	811	627.402 or to benefits specified in s. 627.6513(1) -(14). 546
812	812	3. Alter or amend s. 465.025, which provides conditions 547
813	813	under which a pharmacist may substitute a generically equivalent 548
814	814	drug product for a brand name drug product. 549
815	815	4. Alter or amend s. 465.0252, which provides conditions 550
816	816
817	817	HB 899 2025
818	818
819	819
820	820
821	821	CODING: Words stricken are deletions; words underlined are additions.
822	822	hb899-00
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824	824	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
825	825
826	826
827	827
828	828	under which a pharmacist may dispense a substitute biological 551
829	829	product for the prescribed biological product. 552
830	830	5. Apply to a Medicaid managed care plan under part IV of 553
831	831	chapter 409. 554
832	832	(e) A health maintenance organization shall maintain a 555
833	833	record of any change in its formulary during a calendar year. By 556
834	834	March 1 of each year, a health maintenance organization shall 557
835	835	submit to the office a report delineating such changes made in 558
836	836	the previous calendar y ear. The annual report must include, at a 559
837	837	minimum: 560
838	838	1. A list of all drugs removed from the formulary, along 561
839	839	with the date of the removal and the reasons for the removal. 562
840	840	2. A list of all drugs moved to a tier resulting in 563
841	841	additional out-of-pocket costs to subscribers. 564
842	842	3. The number of subscribers notified by the health 565
843	843	maintenance organization of a change in the formulary. 566
844	844	4. The number of subscribers notified by the health 567
845	845	maintenance organization of a change in the formulary. 568
846	846	5. The increased cost, by dollar amount, incurred by 569
847	847	subscribers because of such change in the formulary. 570
848	848	(f) By May 1 of each year, the office shall: 571
849	849	1. Compile the data in such annual reports submitted by 572
850	850	health maintenance organizations and prepare a report 573
851	851	summarizing the data submitted; 574
852	852	2. Make the report publicly accessible on its website; and 575
853	853
854	854	HB 899 2025
855	855
856	856
857	857
858	858	CODING: Words stricken are deletions; words underlined are additions.
859	859	hb899-00
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861	861	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
862	862
863	863
864	864
865	865	3. Submit the report to the Governor, the President of the 576
866	866	Senate, and the Speaker of the House of Representatives. 577
867	867	(48)(a) As used in this subsection, the term "cost-sharing 578
868	868	requirement" means a dollar limit, a deductible, a copayment, 579
869	869	coinsurance, or any other out -of-pocket expense imposed on a 580
870	870	subscriber, including, but not limited to, the annual limitation 581
871	871	on cost sharing subject to 42 U.S.C. s. 18022. 582
872	872	(b)1. Each health maintenance organization issuing, 583
873	873	delivering, or renewing a health maintenance contract or 584
874	874	certificate in this state which provides prescription drug 585
875	875	coverage, or each pharmacy benefit manager on behalf of such 586
876	876	health maintenance organization, shall apply any amount paid for 587
877	877	a prescription drug by a subscriber or by another person on 588
878	878	behalf of the subscriber toward the subscriber's total 589
879	879	contribution to any cost -sharing requirement if the prescription 590
880	880	drug: 591
881	881	a. Does not have a generic equivale nt; or 592
882	882	b. Has a generic equivalent and the subscriber has 593
883	883	obtained authorization for the prescription drug through any of 594
884	884	the following: 595
885	885	(I) Prior authorization from the health maintenance 596
886	886	organization or pharmacy benefit manager. 597
887	887	(II) A step-therapy protocol. 598
888	888	(III) The exception or appeal process of the health 599
889	889	maintenance organization or pharmacy benefit manager. 600
890	890
891	891	HB 899 2025
892	892
893	893
894	894
895	895	CODING: Words stricken are deletions; words underlined are additions.
896	896	hb899-00
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898	898	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
899	899
900	900
901	901
902	902	2. The amount paid by or on behalf of the subscriber which 601
903	903	is applied toward the subscriber's total contribution to any 602
904	904	cost-sharing requirement under subparagraph 1. includes, but is 603
905	905	not limited to, any payment with or any discount through 604
906	906	financial assistance, a manufacturer copay card, a product 605
907	907	voucher, or any other reduction in out -of-pocket expenses made 606
908	908	by or on behalf of the subsc riber for a prescription drug. 607
909	909	(c) Each health maintenance organization issuing, 608
910	910	delivering, or renewing a health maintenance contract or 609
911	911	certificate in this state which provides prescription drug 610
912	912	coverage, regardless of whether the prescription drug ben efits 611
913	913	are administered or managed by the health maintenance 612
914	914	organization or by a pharmacy benefit manager on behalf of the 613
915	915	health maintenance organization, shall disclose on its website 614
916	916	and in every subscriber's health maintenance contract, 615
917	917	certificate, or member handbook issued, delivered, or renewed in 616
918	918	this state on or after January 1, 2026, that any amount paid by 617
919	919	a subscriber or by another person on behalf of the subscriber 618
920	920	must be applied toward the subscriber's total contribution to 619
921	921	any cost-sharing requirement. 620
922	922	(d)1. A health maintenance organization issuing, 621
923	923	delivering, or renewing a health maintenance contract or 622
924	924	certificate in this state which provides prescription drug 623
925	925	coverage, regardless of whether the prescription drug benefits 624
926	926	are administered or managed by the health maintenance 625
927	927
928	928	HB 899 2025
929	929
930	930
931	931
932	932	CODING: Words stricken are deletions; words underlined are additions.
933	933	hb899-00
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935	935	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
936	936
937	937
938	938
939	939	organization or by a pharmacy benefit manager on behalf of the 626
940	940	health maintenance organization, shall maintain a record of any 627
941	941	third-party payments, made or remitted on behalf of a 628
942	942	subscriber, for prescription drugs, which are not applied to the 629
943	943	subscriber's out-of-pocket obligations, including, but not 630
944	944	limited to, deductibles, copayments, or coinsurance. 631
945	945	2. By March 1 of each year, a health maintenance 632
946	946	organization shall submit to the office a report delineating 633
947	947	third-party payments, as described in subparagraph 1., which 634
948	948	were received in the previous calendar year. The annual report 635
949	949	must include, at a minimum: 636
950	950	a. A list of all payments received by the health 637
951	951	maintenance organization, as described in subparagraph 1., made 638
952	952	or remitted by a third party, which must include: 639
953	953	(I) The date each payment was made. 640
954	954	(II) The prescription drug for which the payment was made. 641
955	955	(III) The reason that the payment was not applied to the 642
956	956	subscriber's out-of-pocket obligations. 643
957	957	b. The total amount of payments received by the health 644
958	958	maintenance organization which were not applied to a 645
959	959	subscriber's out-of-pocket maximum. 646
960	960	c. The total number of subscribers for which a payment was 647
961	961	made which was not applied to an out -of-pocket maximum. 648
962	962	d. Whether such payments were returned to the third party 649
963	963	who submitted the payment. 650
964	964
965	965	HB 899 2025
966	966
967	967
968	968
969	969	CODING: Words stricken are deletions; words underlined are additions.
970	970	hb899-00
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972	972	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
973	973
974	974
975	975
976	976	e. The total amount of payments which were not returned to 651
977	977	the third party who submitted the payment. 652
978	978	(e) This subsection applies to any health maintenance 653
979	979	contract or certificate issued, delivered, or renewed in this 654
980	980	state on or after January 1, 2026. 655
981	981	Section 9. Paragraph (c) is added to subsection (2) of 656
982	982	section 641.314, Florida Statutes, to read: 657
983	983	641.314 Pharmacy benefit manager contracts. — 658
984	984	(2) In addition to the requirements of part VII of chapter 659
985	985	626, a contract between a health maintenance organization and a 660
986	986	pharmacy benefit manager must require that the pharmacy benefit 661
987	987	manager: 662
988	988	(c)1. Apply any amount paid by a subscriber or by another 663
989	989	person on behalf of the subscriber toward the subscriber's total 664
990	990	contribution to any cost -sharing requirement pursuant to s. 665
991	991	641.31(48). This subparagraph applies to any subscriber whose 666
992	992	health maintenance contract or certificate is issued, delivered, 667
993	993	or renewed in this state on or after January 1, 2026. 668
994	994	2. Disclose to every subscriber whose health maintenance 669
995	995	contract or certificate is issued, delivered, or renewed in this 670
996	996	state on or after January 1, 2026, that the pharmacy benefit 671
997	997	manager shall apply any amou nt paid by the subscriber or by 672
998	998	another person on behalf of the subscriber toward the 673
999	999	subscriber's total contribution to any cost -sharing requirement 674
1000	1000	pursuant to s. 641.31(48). 675
1001	1001
1002	1002	HB 899 2025
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1004	1004
1005	1005
1006	1006	CODING: Words stricken are deletions; words underlined are additions.
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1009	1009	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
1010	1010
1011	1011
1012	1012
1013	1013	Section 10. Paragraph (o) of subsection (2) of section 676
1014	1014	409.967, Florida Sta tutes, is amended to read: 677
1015	1015	409.967 Managed care plan accountability. — 678
1016	1016	(2) The agency shall establish such contract requirements 679
1017	1017	as are necessary for the operation of the statewide managed care 680
1018	1018	program. In addition to any other provisions the agency may deem 681
1019	1019	necessary, the contract must require: 682
1020	1020	(o) Transparency.—Managed care plans shall comply with ss. 683
1021	1021	627.6385(4) ss. 627.6385(3) and 641.54(7). 684
1022	1022	Section 11. Paragraph (k) of subsection (1) of section 685
1023	1023	641.185, Florida Statutes, is amended to read: 686
1024	1024	641.185 Health maintenance organization subscriber 687
1025	1025	protections.— 688
1026	1026	(1) With respect to the provisions of this part and part 689
1027	1027	III, the principles expressed in the following statements serve 690
1028	1028	as standards to be followed by the commission, the office, the 691
1029	1029	department, and the Agency for Health Care Administration in 692
1030	1030	exercising their powers and duties, in exercising administrative 693
1031	1031	discretion, in administrative interpretations of the law, in 694
1032	1032	enforcing its provisions, and in adopting rules: 695
1033	1033	(k) A health maintenan ce organization subscriber shall be 696
1034	1034	given a copy of the applicable health maintenance contract, 697
1035	1035	certificate, or member handbook specifying: all the provisions, 698
1036	1036	disclosure, and limitations required pursuant to s. 641.31(1) , 699
1037	1037	and (4), and (48); the covered services, including those 700
1038	1038
1039	1039	HB 899 2025
1040	1040
1041	1041
1042	1042
1043	1043	CODING: Words stricken are deletions; words underlined are additions.
1044	1044	hb899-00
1045	1045	Page 29 of 29
1046	1046	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
1047	1047
1048	1048
1049	1049
1050	1050	services, medical conditions, and provider types specified in 701
1051	1051	ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 702
1052	1052	641.513; and where and in what manner services may be obtained 703
1053	1053	pursuant to s. 641.31(4). 704
1054	1054	Section 12. This act applies to health insurance policies, 705
1055	1055	health benefit plans, and health maintenance contracts entered 706
1056	1056	into or renewed on or after January 1, 2026. 707
1057	1057	Section 13. The Legislature finds that this act fulfills 708
1058	1058	an important state interest. 709
1059	1059	Section 14. This act shall take effect July 1, 2025. 710