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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to insurer disclosures on prescription 2
drug coverage; creating s. 627.42394, F.S.; requiring 3
individual and group health insurers to provide notice 4
of prescription drug formulary changes within a 5
certain timeframe to current and prospective insureds 6
and the insureds' treating physicians; specifying 7
requirements for the content of such notice and the 8
manner in which it must be provided; specifying 9
requirements for a notice of medical necessity 10
submitted by the treating physician; authorizing 11
insurers to provide certain means for submitting the 12
notice of medical necessity; requiring the Financial 13
Services Commission to adopt a certain form by rule by 14
a specified date; specifying a coverage requirement 15
and restrictions on coverage modification b y insurers 16
receiving a notice of medical necessity; providing 17
construction and applicability; requiring insurers to 18
maintain a record of formulary changes; requiring 19
insurers to annually submit a specified report to the 20
Office of Insurance Regulation by a specified date; 21
requiring the office to annually compile certain data 22
and prepare a report, make the report publicly 23
accessible on its website, and submit the report to 24
the Governor and the Legislature by a specified date; 25
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creating s. 627.6383, F.S.; defin ing the term "cost-26
sharing requirement"; requiring specified individual 27
health insurers and their pharmacy benefit managers to 28
apply payments for prescription drugs by or on behalf 29
of insureds toward the total contributions of the 30
insureds' cost-sharing requirements under certain 31
circumstances; providing construction; requiring 32
specified individual health insurers to maintain 33
records of certain third -party payments for 34
prescription drugs; providing reporting requirements; 35
providing requirements for the repo rts; providing 36
applicability; amending s. 627.6385, F.S.; providing 37
disclosure requirements; providing applicability; 38
amending s. 627.64741, F.S.; requiring specified 39
contracts to require pharmacy benefit managers to 40
apply payments by or on behalf of insur eds toward the 41
insureds' total contributions to cost -sharing 42
requirements; providing applicability; providing 43
disclosure requirements; creating s. 627.65715, F.S.; 44
defining the term "cost -sharing requirement"; 45
requiring specified group health insurers and their 46
pharmacy benefit managers to apply payments for 47
prescription drugs by or on behalf of insureds toward 48
the total contributions of the insureds' cost -sharing 49
requirements under certain circumstances; providing 50
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construction; providing disclosure require ments; 51
requiring specified group health insurers to maintain 52
records of certain third -party payments for 53
prescription drugs; providing reporting requirements; 54
providing requirements for the reports; providing 55
applicability; amending s. 627.6572, F.S.; requ iring 56
specified contracts to require pharmacy benefit 57
managers to apply payments by or on behalf of insureds 58
toward the insureds' total contributions to cost -59
sharing requirements; providing applicability; 60
providing disclosure requirements; amending s. 61
627.6699, F.S.; requiring small employer carriers to 62
comply with certain requirements for prescription drug 63
formulary changes; amending s. 641.31, F.S.; providing 64
an exception to requirements relating to changes in a 65
health maintenance organization's group con tract; 66
requiring health maintenance organizations to provide 67
notice of prescription drug formulary changes within a 68
certain timeframe to current and prospective 69
subscribers and the subscribers' treating physicians; 70
specifying requirements for the content o f such notice 71
and the manner in which it must be provided; 72
specifying requirements for a notice of medical 73
necessity submitted by the treating physician; 74
authorizing health maintenance organizations to 75
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provide certain means for submitting the notice of 76
medical necessity; requiring the commission to adopt a 77
certain form by rule by a specified date; specifying a 78
coverage requirement and restrictions on coverage 79
modification by health maintenance organizations 80
receiving a notice of medical necessity; providing 81
construction and applicability; requiring health 82
maintenance organizations to maintain a record of 83
formulary changes; requiring health maintenance 84
organizations to annually submit a specified report to 85
the office by a specified date; requiring the office 86
to annually compile certain data and prepare a report, 87
make the report publicly accessible on its website, 88
and submit the report to the Governor and the 89
Legislature by a specified date; defining the term 90
"cost-sharing requirement"; requiring specified heal th 91
maintenance organizations and their pharmacy benefit 92
managers to apply payments for prescription drugs by 93
or on behalf of subscribers toward the total 94
contributions of the subscribers' cost -sharing 95
requirements under certain circumstances; providing 96
construction; providing disclosure requirements; 97
requiring specified health maintenance organizations 98
to maintain records of certain third -party payments 99
for prescription drugs; providing reporting 100
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requirements; providing requirements for the reports; 101
providing applicability; amending s. 641.314, F.S.; 102
requiring specified contracts to require pharmacy 103
benefit managers to apply payments by or on behalf of 104
subscribers toward the subscribers' total 105
contributions to cost -sharing requirements; providing 106
applicability; providing disclosure requirements; 107
amending s. 409.967, F.S.; conforming a cross -108
reference; amending s. 641.185, F.S.; conforming a 109
provision to changes made by the act; providing 110
applicability; providing a declaration of important 111
state interest; prov iding an effective date. 112
113
Be It Enacted by the Legislature of the State of Florida: 114
115
Section 1. Section 627.42394, Florida Statutes, is created 116
to read: 117
627.42394 Health insurance policies; changes to 118
prescription drug formularies; requirements. — 119
(1) At least 60 days before the effective date of any 120
change to a prescription drug formulary during a policy year, an 121
insurer issuing individual or group health insurance policies in 122
the state shall notify: 123
(a) Current and prospective insureds of the change in the 124
formulary in a readily accessible format on the insurer's 125
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website; and 126
(b) Any insured currently receiving coverage for a 127
prescription drug for which the formulary change modifies 128
coverage and the insured's treating physician. Such notific ation 129
must be sent electronically and by first -class mail and must 130
include information on the specific drugs involved and a 131
statement that the submission of a notice of medical necessity 132
by the insured's treating physician to the insurer at least 30 133
days before the effective date of the formulary change will 134
result in continuation of coverage at the existing level. 135
(2) The notice provided by the treating physician to the 136
insurer must include a completed one -page form in which the 137
treating physician certif ies to the insurer that the 138
prescription drug for the insured is medically necessary as 139
defined in s. 627.732(2). The treating physician shall submit 140
the notice electronically or by first -class mail. The insurer 141
may provide the treating physician with acce ss to an electronic 142
portal through which the treating physician may electronically 143
submit the notice. By January 1, 2026, the commission shall 144
adopt by rule a form for the notice. 145
(3) If the treating physician certifies to the insurer in 146
accordance with subsection (2) that the prescription drug is 147
medically necessary for the insured, the insurer: 148
(a) Must authorize coverage for the prescribed drug until 149
the end of the policy year, based solely on the treating 150
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physician's certification that the drug is m edically necessary; 151
and 152
(b) May not modify the coverage related to the covered 153
drug during the policy year by: 154
1. Increasing the out -of-pocket costs for the covered 155
drug; 156
2. Moving the covered drug to a more restrictive tier; 157
3. Denying an insured coverage of the drug for which the 158
insured has been previously approved for coverage by the 159
insurer; or 160
4. Limiting or reducing coverage of the drug in any other 161
way, including subjecting it to a new prior authorization or 162
step-therapy requirement. 163
(4) Subsections (1), (2), and (3) do not: 164
(a) Prohibit the addition of prescription drugs to the 165
list of drugs covered under the policy during the policy year. 166
(b) Apply to a grandfathered health plan as defined in s. 167
627.402 or to benefits specified in s . 627.6513(1)-(14). 168
(c) Alter or amend s. 465.025, which provides conditions 169
under which a pharmacist may substitute a generically equivalent 170
drug product for a brand name drug product. 171
(d) Alter or amend s. 465.0252, which provides conditions 172
under which a pharmacist may dispense a substitute biological 173
product for the prescribed biological product. 174
(e) Apply to a Medicaid managed care plan under part IV of 175
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chapter 409. 176
(5) A health insurer shall maintain a record of any change 177
in its formulary dur ing a calendar year. By March 1 of each 178
year, a health insurer shall submit to the office a report 179
delineating such changes made in the previous calendar year. The 180
annual report must include, at a minimum: 181
(a) A list of all drugs removed from the formula ry, along 182
with the date of the removal and the reasons for the removal. 183
(b) A list of all drugs moved to a tier resulting in 184
additional out-of-pocket costs to insureds. 185
(c) The number of insureds impacted by a change in the 186
formulary. 187
(d) The number of insureds notified by the insurer of a 188
change in the formulary. 189
(e) The increased cost, by dollar amount, incurred by 190
insureds because of such change in the formulary. 191
(6) By May 1 of each year, the office shall: 192
(a) Compile the data in the annual reports submitted by 193
health insurers under subsection (5) and prepare a report 194
summarizing the data submitted. 195
(b) Make the report publicly accessible on its website. 196
(c) Submit the report to the Governor, the President of 197
the Senate, and the Speaker o f the House of Representatives. 198
Section 2. Section 627.6383, Florida Statutes, is created 199
to read: 200
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627.6383 Cost-sharing requirements. — 201
(1) As used in this section, the term "cost -sharing 202
requirement" means a dollar limit, a deductible, a copayment , 203
coinsurance, or any other out -of-pocket expense imposed on an 204
insured, including, but not limited to, the annual limitation on 205
cost sharing subject to 42 U.S.C. s. 18022. 206
(2)(a) Each health insurer issuing, delivering, or 207
renewing a policy in this stat e which provides prescription drug 208
coverage, or each pharmacy benefit manager on behalf of such 209
health insurer, shall apply any amount paid for a prescription 210
drug by an insured or by another person on behalf of the insured 211
toward the insured's total contr ibution to any cost-sharing 212
requirement, if the prescription drug: 213
1. Does not have a generic equivalent; or 214
2. Has a generic equivalent and the insured has obtained 215
authorization for the prescription drug through any of the 216
following: 217
a. Prior authorization from the health insurer or pharmacy 218
benefit manager. 219
b. A step-therapy protocol. 220
c. The exception or appeal process of the health insurer 221
or pharmacy benefit manager. 222
(b) The amount paid by or on behalf of the insured which 223
is applied toward the insured's total contribution to any cost -224
sharing requirement under paragraph (a) includes, but is not 225
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limited to, any payment with or any discount through financial 226
assistance, a manufacturer copay card, a product voucher, or any 227
other reduction in ou t-of-pocket expenses made by or on behalf 228
of the insured for a prescription drug. 229
(c)1. Each health insurer issuing, delivering, or renewing 230
a policy in this state which provides prescription drug 231
coverage, regardless of whether the prescription drug benefits 232
are administered or managed by the insurer or by a pharmacy 233
benefit manager on behalf of the insurer, shall maintain a 234
record of any third-party payments, made or remitted on behalf 235
of an insured, for prescription drugs, which are not applied to 236
the insured's out-of-pocket obligations, including, but not 237
limited to, deductibles, copayments, or coinsurance. 238
2. By March 1 of each year, each health insurer issuing, 239
delivering, or renewing a policy in this state which provides 240
prescription drug cover age, regardless of whether the 241
prescription drug benefits are administered or managed by the 242
insurer or by a pharmacy benefit manager on behalf of the 243
insurer, shall submit to the office a report delineating third -244
party payments, as described in subparagra ph 1., which were 245
received in the previous calendar year. The annual report must 246
include, at a minimum: 247
a. A list of all payments received by the health insurer, 248
as described in subparagraph 1., made or remitted by a third 249
party, which must include: 250
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(I) The date each payment was made. 251
(II) The prescription drug for which the payment was made. 252
(III) The reason that the payment was not applied to the 253
insured's out-of-pocket obligations. 254
b. The total amount of payments received by the health 255
insurer which were not applied to an insured's out -of-pocket 256
maximum. 257
c. The total number of insureds for which a payment was 258
made which was not applied to an out -of-pocket maximum. 259
d. Whether such payments were returned to the third party 260
who submitted the pa yment. 261
e. The total amount of payments which were not returned to 262
the third party who submitted the payment. 263
(3) This section applies to any health insurance policy 264
issued, delivered, or renewed in this state on or after January 265
1, 2026. 266
Section 3. Subsections (2) and (3) of section 627.6385, 267
Florida Statutes, are renumbered as subsections (3) and (4), 268
respectively, present subsection (2) of that section is amended, 269
and a new subsection (2) is added to that section, to read: 270
627.6385 Disclosures t o policyholders; calculations of 271
cost sharing.— 272
(2) Each health insurer issuing, delivering, or renewing a 273
policy in this state which provides prescription drug coverage, 274
regardless of whether the prescription drug benefits are 275
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administered or managed by the health insurer or by a pharmacy 276
benefit manager on behalf of the health insurer, shall disclose 277
on its website that any amount paid by a policyholder or by 278
another person on behalf of the policyholder must be applied 279
toward the policyholder's total co ntribution to any cost -sharing 280
requirement pursuant to s. 627.6383. This subsection applies to 281
any policy issued, delivered, or renewed in this state on or 282
after January 1, 2026. 283
(3)(2) Each health insurer shall include in every policy 284
delivered or issued for delivery to any person in this the state 285
or in materials provided as required by s. 627.64725 a notice 286
that the information required by this section is available 287
electronically and the website address of the website where the 288
information can be acces sed. In addition, each health insurer 289
issuing, delivering, or renewing a policy in this state which 290
provides prescription drug coverage, regardless of whether the 291
prescription drug benefits are administered or managed by the 292
health insurer or by a pharmacy benefit manager on behalf of the 293
health insurer, shall disclose in every policy that is issued, 294
delivered, or renewed to any person in this state on or after 295
January 1, 2026, that any amount paid by a policyholder or by 296
another person on behalf of the pol icyholder must be applied 297
toward the policyholder's total contribution to any cost -sharing 298
requirement pursuant to s. 627.6383. 299
Section 4. Paragraph (c) is added to subsection (2) of 300
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section 627.64741, Florida Statutes, to read: 301
627.64741 Pharmacy be nefit manager contracts. — 302
(2) In addition to the requirements of part VII of chapter 303
626, a contract between a health insurer and a pharmacy benefit 304
manager must require that the pharmacy benefit manager: 305
(c)1. Apply any amount paid by an insured or by another 306
person on behalf of the insured toward the insured's total 307
contribution to any cost -sharing requirement pursuant to s. 308
627.6383. This subparagraph applies to any insured whose 309
insurance policy is issued, delivered, or renewed in this state 310
on or after January 1, 2026. 311
2. Disclose to every insured whose insurance policy is 312
issued, delivered, or renewed in this state on or after January 313
1, 2026, that the pharmacy benefit manager shall apply any 314
amount paid by the insured or by another person on beh alf of the 315
insured toward the insured's total contribution to any cost -316
sharing requirement pursuant to s. 627.6383. 317
Section 5. Section 627.65715, Florida Statutes, is created 318
to read: 319
627.65715 Cost-sharing requirements. — 320
(1) As used in this sectio n, the term "cost-sharing 321
requirement" means a dollar limit, a deductible, a copayment, 322
coinsurance, or any other out -of-pocket expense imposed on an 323
insured, including, but not limited to, the annual limitation on 324
cost sharing subject to 42 U.S.C. s. 1802 2. 325
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(2)(a) Each insurer issuing, delivering, or renewing a 326
policy in this state which provides prescription drug coverage, 327
or each pharmacy benefit manager on behalf of such insurer, 328
shall apply any amount paid for a prescription drug by an 329
insured or by another person on behalf of the insured toward the 330
insured's total contribution to any cost -sharing requirement, if 331
the prescription drug: 332
1. Does not have a generic equivalent; or 333
2. Has a generic equivalent and the insured has obtained 334
authorization for the prescription drug through any of the 335
following: 336
a. Prior authorization from the health insurer or pharmacy 337
benefit manager. 338
b. A step-therapy protocol. 339
c. The exception or appeal process of the health insurer 340
or pharmacy benefit manager. 341
(b) The amount paid by or on behalf of the insured which 342
is applied toward the insured's total contribution to any cost -343
sharing requirement under paragraph (a) includes, but is not 344
limited to, any payment with or any discount through financial 345
assistance, a manufacturer copay card, a product voucher, or any 346
other reduction in out -of-pocket expenses made by or on behalf 347
of the insured for a prescription drug. 348
(3)(a) Each insurer issuing, delivering, or renewing a 349
policy in this state which provides prescript ion drug coverage, 350
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regardless of whether the prescription drug benefits are 351
administered or managed by the insurer or by a pharmacy benefit 352
manager on behalf of the insurer, shall disclose on its website 353
and in every policy issued, delivered, or renewed in this state 354
on or after January 1, 2026, that any amount paid by an insured 355
or by another person on behalf of the insured must be applied 356
toward the insured's total contribution to any cost -sharing 357
requirement. 358
(b)1. Each health insurer issuing, delivering, or renewing 359
a policy in this state which provides prescription drug 360
coverage, regardless of whether the prescription drug benefits 361
are administered or managed by the insurer or by a pharmacy 362
benefit manager on behalf of the insurer, shall maint ain a 363
record of any third-party payments, made or remitted on behalf 364
of an insured, for prescription drugs, which are not applied to 365
the insured's out-of-pocket obligations, including, but not 366
limited to, deductibles, copayments, or coinsurance. 367
2. By March 1 of each year, each health insurer issuing, 368
delivering, or renewing a policy in this state which provides 369
prescription drug coverage, regardless of whether the 370
prescription drug benefits are administered or managed by the 371
insurer or by a pharmacy bene fit manager on behalf of the 372
insurer, shall submit to the office a report delineating third -373
party payments, as described in subparagraph 1., which were 374
received in the previous calendar year. The annual report must 375
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include, at a minimum: 376
a. A list of all payments received by the health insurer, 377
as described in subparagraph 1., made or remitted by a third 378
party, which must include: 379
(I) The date each payment was made. 380
(II) The prescription drug for which the payment was made. 381
(III) The reason that the payment was not applied to the 382
insured's out-of-pocket obligations. 383
b. The total amount of payments received by the health 384
insurer which were not applied to an insured's out -of-pocket 385
maximum. 386
c. The total number of insureds for which a payment was 387
made which was not applied to an out -of-pocket maximum. 388
d. Whether such payments were returned to the third party 389
who submitted the payment. 390
e. The total amount of payments which were not returned to 391
the third party who submitted the payment. 392
(4) This section applies to any group health insurance 393
policy issued, delivered, or renewed in this state on or after 394
January 1, 2026. 395
Section 6. Paragraph (c) is added to subsection (2) of 396
section 627.6572, Florida Statutes, to read: 397
627.6572 Pharmacy bene fit manager contracts. — 398
(2) In addition to the requirements of part VII of chapter 399
626, a contract between a health insurer and a pharmacy benefit 400
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manager must require that the pharmacy benefit manager: 401
(c)1. Apply any amount paid by an insured or by a nother 402
person on behalf of the insured toward the insured's total 403
contribution to any cost -sharing requirement pursuant to s. 404
627.65715. This subparagraph applies to any insured whose 405
insurance policy is issued, delivered, or renewed in this state 406
on or after January 1, 2026. 407
2. Disclose to every insured whose insurance policy is 408
issued, delivered, or renewed in this state on or after January 409
1, 2026, that the pharmacy benefit manager shall apply any 410
amount paid by the insured or by another person on beha lf of the 411
insured toward the insured's total contribution to any cost -412
sharing requirement pursuant to s. 627.65715. 413
Section 7. Paragraph (e) of subsection (5) of section 414
627.6699, Florida Statutes, is amended to read: 415
627.6699 Employee Health Care Ac cess Act.— 416
(5) AVAILABILITY OF COVERAGE. — 417
(e) All health benefit plans issued under this section 418
must comply with the following conditions: 419
1. For employers who have fewer than two employees, a late 420
enrollee may be excluded from coverage for no longe r than 24 421
months if he or she was not covered by creditable coverage 422
continually to a date not more than 63 days before the effective 423
date of his or her new coverage. 424
2. Any requirement used by a small employer carrier in 425
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determining whether to provide c overage to a small employer 426
group, including requirements for minimum participation of 427
eligible employees and minimum employer contributions, must be 428
applied uniformly among all small employer groups having the 429
same number of eligible employees applying fo r coverage or 430
receiving coverage from the small employer carrier, except that 431
a small employer carrier that participates in, administers, or 432
issues health benefits pursuant to s. 381.0406 which do not 433
include a preexisting condition exclusion may require a s a 434
condition of offering such benefits that the employer has had no 435
health insurance coverage for its employees for a period of at 436
least 6 months. A small employer carrier may vary application of 437
minimum participation requirements and minimum employer 438
contribution requirements only by the size of the small employer 439
group. 440
3. In applying minimum participation requirements with 441
respect to a small employer, a small employer carrier may shall 442
not consider as an eligible employee employees or dependents who 443
have qualifying existing coverage in an employer -based group 444
insurance plan or an ERISA qualified self -insurance plan in 445
determining whether the applicable percentage of participation 446
is met. However, a small employer carrier may count eligible 447
employees and dependents who have coverage under another health 448
plan that is sponsored by that employer. 449
4. A small employer carrier may shall not increase any 450
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requirement for minimum employee participation or any 451
requirement for minimum employer contribution applic able to a 452
small employer at any time after the small employer has been 453
accepted for coverage, unless the employer size has changed, in 454
which case the small employer carrier may apply the requirements 455
that are applicable to the new group size. 456
5. If a small employer carrier offers coverage to a small 457
employer, it must offer coverage to all the small employer's 458
eligible employees and their dependents. A small employer 459
carrier may not offer coverage limited to certain persons in a 460
group or to part of a group , except with respect to late 461
enrollees. 462
6. A small employer carrier may not modify any health 463
benefit plan issued to a small employer with respect to a small 464
employer or any eligible employee or dependent through riders, 465
endorsements, or otherwise to re strict or exclude coverage for 466
certain diseases or medical conditions otherwise covered by the 467
health benefit plan. 468
7. An initial enrollment period of at least 30 days must 469
be provided. An annual 30 -day open enrollment period must be 470
offered to each smal l employer's eligible employees and their 471
dependents. A small employer carrier must provide special 472
enrollment periods as required by s. 627.65615. 473
8. A small employer carrier shall comply with s. 627.65715 474
for any change to a prescription drug formulary . 475
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Section 8. Subsection (36) of section 641.31, Florida 476
Statutes, is amended, and subsection (48) is added to that 477
section, to read: 478
641.31 Health maintenance contracts. — 479
(36) Except as provided in paragraphs (a), (b), and (c), a 480
health maintenance organization may increase the copayment for 481
any benefit, or delete, amend, or limit any of the benefits to 482
which a subscriber is entitled under the group contract only, 483
upon written notice to the contract holder at least 45 days in 484
advance of the time of coverage renewal. The health maintenance 485
organization may amend the contract with the contract holder, 486
with such amendment to be effective immediately at the time of 487
coverage renewal. The written notice to the contract holder must 488
shall specifically identify any deletions, amendments, or 489
limitations to any of the benefits provided in the group 490
contract during the current contract period which will be 491
included in the group contract upon renewal. This subsection 492
does not apply to any incr eases in benefits. The 45 -day notice 493
requirement does shall not apply if benefits are amended, 494
deleted, or limited at the request of the contract holder. 495
(a) At least 60 days before the effective date of any 496
change to a prescription drug formulary during a contract year, 497
a health maintenance organization shall notify: 498
1. Current and prospective subscribers of the change in 499
the formulary in a readily accessible format on the health 500
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maintenance organization's website; and 501
2. Any subscriber currently rec eiving coverage for a 502
prescription drug for which the formulary change modifies 503
coverage and the subscriber's treating physician. Such 504
notification must be sent electronically and by first -class mail 505
and must include information on the specific drugs invol ved and 506
a statement that the submission of a notice of medical necessity 507
by the subscriber's treating physician to the health maintenance 508
organization at least 30 days before the effective date of the 509
formulary change will result in continuation of coverag e at the 510
existing level. 511
(b) The notice provided by the treating physician to the 512
health maintenance organization must include a completed one -513
page form in which the treating physician certifies to the 514
health maintenance organization that the prescriptio n drug for 515
the subscriber is medically necessary as defined in s. 516
627.732(2). The treating physician shall submit the notice 517
electronically or by first -class mail. The health maintenance 518
organization may provide the treating physician with access to 519
an electronic portal through which the treating physician may 520
electronically submit the notice. By January 1, 2026, the 521
commission shall adopt by rule a form for the notice. 522
(c) If the treating physician certifies to the health 523
maintenance organization in acco rdance with paragraph (b) that 524
the prescription drug is medically necessary for the subscriber, 525
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the health maintenance organization: 526
1. Must authorize coverage for the prescribed drug until 527
the end of the contract year, based solely on the treating 528
physician's certification that the drug is medically necessary; 529
and 530
2. May not modify the coverage related to the covered drug 531
during the contract year by: 532
a. Increasing the out -of-pocket costs for the covered 533
drug; 534
b. Moving the covered drug to a more re strictive tier; 535
c. Denying a subscriber coverage of the drug for which the 536
subscriber has been previously approved for coverage by the 537
health maintenance organization; or 538
d. Limiting or reducing coverage of the drug in any other 539
way, including subjecti ng it to a new prior authorization or 540
step-therapy requirement. 541
(d) Paragraphs (a), (b), and (c) do not: 542
1. Prohibit the addition of prescription drugs to the list 543
of drugs covered under the contract during the contract year. 544
2. Apply to a grandfathe red health plan as defined in s. 545
627.402 or to benefits specified in s. 627.6513(1) -(14). 546
3. Alter or amend s. 465.025, which provides conditions 547
under which a pharmacist may substitute a generically equivalent 548
drug product for a brand name drug product. 549
4. Alter or amend s. 465.0252, which provides conditions 550
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under which a pharmacist may dispense a substitute biological 551
product for the prescribed biological product. 552
5. Apply to a Medicaid managed care plan under part IV of 553
chapter 409. 554
(e) A health maintenance organization shall maintain a 555
record of any change in its formulary during a calendar year. By 556
March 1 of each year, a health maintenance organization shall 557
submit to the office a report delineating such changes made in 558
the previous calendar y ear. The annual report must include, at a 559
minimum: 560
1. A list of all drugs removed from the formulary, along 561
with the date of the removal and the reasons for the removal. 562
2. A list of all drugs moved to a tier resulting in 563
additional out-of-pocket costs to subscribers. 564
3. The number of subscribers notified by the health 565
maintenance organization of a change in the formulary. 566
4. The number of subscribers notified by the health 567
maintenance organization of a change in the formulary. 568
5. The increased cost, by dollar amount, incurred by 569
subscribers because of such change in the formulary. 570
(f) By May 1 of each year, the office shall: 571
1. Compile the data in such annual reports submitted by 572
health maintenance organizations and prepare a report 573
summarizing the data submitted; 574
2. Make the report publicly accessible on its website; and 575
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3. Submit the report to the Governor, the President of the 576
Senate, and the Speaker of the House of Representatives. 577
(48)(a) As used in this subsection, the term "cost-sharing 578
requirement" means a dollar limit, a deductible, a copayment, 579
coinsurance, or any other out -of-pocket expense imposed on a 580
subscriber, including, but not limited to, the annual limitation 581
on cost sharing subject to 42 U.S.C. s. 18022. 582
(b)1. Each health maintenance organization issuing, 583
delivering, or renewing a health maintenance contract or 584
certificate in this state which provides prescription drug 585
coverage, or each pharmacy benefit manager on behalf of such 586
health maintenance organization, shall apply any amount paid for 587
a prescription drug by a subscriber or by another person on 588
behalf of the subscriber toward the subscriber's total 589
contribution to any cost -sharing requirement if the prescription 590
drug: 591
a. Does not have a generic equivale nt; or 592
b. Has a generic equivalent and the subscriber has 593
obtained authorization for the prescription drug through any of 594
the following: 595
(I) Prior authorization from the health maintenance 596
organization or pharmacy benefit manager. 597
(II) A step-therapy protocol. 598
(III) The exception or appeal process of the health 599
maintenance organization or pharmacy benefit manager. 600
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2. The amount paid by or on behalf of the subscriber which 601
is applied toward the subscriber's total contribution to any 602
cost-sharing requirement under subparagraph 1. includes, but is 603
not limited to, any payment with or any discount through 604
financial assistance, a manufacturer copay card, a product 605
voucher, or any other reduction in out -of-pocket expenses made 606
by or on behalf of the subsc riber for a prescription drug. 607
(c) Each health maintenance organization issuing, 608
delivering, or renewing a health maintenance contract or 609
certificate in this state which provides prescription drug 610
coverage, regardless of whether the prescription drug ben efits 611
are administered or managed by the health maintenance 612
organization or by a pharmacy benefit manager on behalf of the 613
health maintenance organization, shall disclose on its website 614
and in every subscriber's health maintenance contract, 615
certificate, or member handbook issued, delivered, or renewed in 616
this state on or after January 1, 2026, that any amount paid by 617
a subscriber or by another person on behalf of the subscriber 618
must be applied toward the subscriber's total contribution to 619
any cost-sharing requirement. 620
(d)1. A health maintenance organization issuing, 621
delivering, or renewing a health maintenance contract or 622
certificate in this state which provides prescription drug 623
coverage, regardless of whether the prescription drug benefits 624
are administered or managed by the health maintenance 625
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organization or by a pharmacy benefit manager on behalf of the 626
health maintenance organization, shall maintain a record of any 627
third-party payments, made or remitted on behalf of a 628
subscriber, for prescription drugs, which are not applied to the 629
subscriber's out-of-pocket obligations, including, but not 630
limited to, deductibles, copayments, or coinsurance. 631
2. By March 1 of each year, a health maintenance 632
organization shall submit to the office a report delineating 633
third-party payments, as described in subparagraph 1., which 634
were received in the previous calendar year. The annual report 635
must include, at a minimum: 636
a. A list of all payments received by the health 637
maintenance organization, as described in subparagraph 1., made 638
or remitted by a third party, which must include: 639
(I) The date each payment was made. 640
(II) The prescription drug for which the payment was made. 641
(III) The reason that the payment was not applied to the 642
subscriber's out-of-pocket obligations. 643
b. The total amount of payments received by the health 644
maintenance organization which were not applied to a 645
subscriber's out-of-pocket maximum. 646
c. The total number of subscribers for which a payment was 647
made which was not applied to an out -of-pocket maximum. 648
d. Whether such payments were returned to the third party 649
who submitted the payment. 650
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e. The total amount of payments which were not returned to 651
the third party who submitted the payment. 652
(e) This subsection applies to any health maintenance 653
contract or certificate issued, delivered, or renewed in this 654
state on or after January 1, 2026. 655
Section 9. Paragraph (c) is added to subsection (2) of 656
section 641.314, Florida Statutes, to read: 657
641.314 Pharmacy benefit manager contracts. — 658
(2) In addition to the requirements of part VII of chapter 659
626, a contract between a health maintenance organization and a 660
pharmacy benefit manager must require that the pharmacy benefit 661
manager: 662
(c)1. Apply any amount paid by a subscriber or by another 663
person on behalf of the subscriber toward the subscriber's total 664
contribution to any cost -sharing requirement pursuant to s. 665
641.31(48). This subparagraph applies to any subscriber whose 666
health maintenance contract or certificate is issued, delivered, 667
or renewed in this state on or after January 1, 2026. 668
2. Disclose to every subscriber whose health maintenance 669
contract or certificate is issued, delivered, or renewed in this 670
state on or after January 1, 2026, that the pharmacy benefit 671
manager shall apply any amou nt paid by the subscriber or by 672
another person on behalf of the subscriber toward the 673
subscriber's total contribution to any cost -sharing requirement 674
pursuant to s. 641.31(48). 675
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Section 10. Paragraph (o) of subsection (2) of section 676
409.967, Florida Sta tutes, is amended to read: 677
409.967 Managed care plan accountability. — 678
(2) The agency shall establish such contract requirements 679
as are necessary for the operation of the statewide managed care 680
program. In addition to any other provisions the agency may deem 681
necessary, the contract must require: 682
(o) Transparency.—Managed care plans shall comply with ss. 683
627.6385(4) ss. 627.6385(3) and 641.54(7). 684
Section 11. Paragraph (k) of subsection (1) of section 685
641.185, Florida Statutes, is amended to read: 686
641.185 Health maintenance organization subscriber 687
protections.— 688
(1) With respect to the provisions of this part and part 689
III, the principles expressed in the following statements serve 690
as standards to be followed by the commission, the office, the 691
department, and the Agency for Health Care Administration in 692
exercising their powers and duties, in exercising administrative 693
discretion, in administrative interpretations of the law, in 694
enforcing its provisions, and in adopting rules: 695
(k) A health maintenan ce organization subscriber shall be 696
given a copy of the applicable health maintenance contract, 697
certificate, or member handbook specifying: all the provisions, 698
disclosure, and limitations required pursuant to s. 641.31(1) , 699
and (4), and (48); the covered services, including those 700
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services, medical conditions, and provider types specified in 701
ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 702
641.513; and where and in what manner services may be obtained 703
pursuant to s. 641.31(4). 704
Section 12. This act applies to health insurance policies, 705
health benefit plans, and health maintenance contracts entered 706
into or renewed on or after January 1, 2026. 707
Section 13. The Legislature finds that this act fulfills 708
an important state interest. 709
Section 14. This act shall take effect July 1, 2025. 710