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
HB 363 2024
1 A bill to be entitled
2 An act relating to health insurance cost sharing;
3 creating s. 627.6383, F.S.; defining the term "cost -
4 sharing requirement"; requiring specified individual
5 health insurers and their pharmacy benefit managers to
6 apply payments for prescription drugs by or on behalf
7 of insureds toward the total contributions of the
8 insureds' cost-sharing requirements under certain
9 circumstances; providing construction; providing
10 applicability; amending s. 627.6385, F.S.; providing
11 disclosure requirements; providing applicability;
12 amending s. 627.64741, F.S.; requiring specified
13 contracts to require pharmacy benefit managers to
14 apply payments by or on behalf of insureds toward the
15 insureds' total contributions to cost-sharing
16 requirements; providing applicability; providing
17 disclosure requirements; creating s. 627.65715, F.S.;
18 defining the term "cost-sharing requirement";
19 requiring specified group health insurers and their
20 pharmacy benefit managers to apply payments for
21 prescription drugs by or on behalf of insureds toward
22 the total contributions of the insureds' cost-sharing
23 requirements under certain circumstances; providing
24 construction; providing disclosure requirements;
25 providing applicability; amending s. 627.6572, F.S.;
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26 requiring specified contracts to require pharmacy
27 benefit managers to apply payments by or on behalf of
28 insureds toward the insureds' total contributions to
29 cost-sharing requirements; providing applicability;
30 providing disclosure requirements; amending s.
31 627.6699, F.S.; making technical changes; requiring
32 small employer carriers to comply with certain cost -
33 sharing requirements; amending s. 641.31, F.S.;
34 defining the term "cost-sharing requirement";
35 requiring specified health maintenance organizations
36 and their pharmacy benefit managers to apply payments
37 for prescription drugs by or on behalf of subscribers
38 toward the total contributions of the subscribers'
39 cost-sharing requirements under certain circumstances;
40 providing construction; providing disclosure
41 requirements; providing applicability; amending s.
42 641.314, F.S.; requiring specified contracts to
43 require pharmacy benefit managers to apply payments by
44 or on behalf of subscribers toward the subscribers'
45 total contributions to cost-sharing requirements;
46 providing applicability; providing disclosure
47 requirements; amending s. 409.967, F.S.; conforming a
48 cross-reference; amending s. 641.185, F.S.; conforming
49 a provision to changes made by the act; providing a
50 declaration of important state interest; providing an
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51 effective date.
52
53 Be It Enacted by the Legislature of the State of Florida:
54
55 Section 1. Section 627.6383, Florida Statutes, is created
56 to read:
57 627.6383 Cost-sharing requirements.—
58 (1) As used in this section, the term "cost-sharing
59 requirement" means a dollar limit, a deductible, a copayment,
60 coinsurance, or any other out-of-pocket expense imposed on an
61 insured, including, but not limited to, the annual limitation on
62 cost sharing subject to 42 U.S.C. s. 18022.
63 (2)(a) Each health insurer issuing, delivering, or
64 renewing a policy in this state which provides prescription drug
65 coverage, or each pharmacy benefit manager on behalf of such
66 health insurer, shall apply any amount paid for a prescription
67 drug by an insured or by another person on behalf of the insured
68 toward the insured's total contribution to any cost -sharing
69 requirement, if the prescription drug:
70 1. Does not have a generic equivalent; or
71 2. Has a generic equivalent and the insured has obtained
72 authorization for the prescription drug through any of the
73 following:
74 a. Prior authorization from the health insurer or pharmacy
75 benefit manager.
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76 b. A step-therapy protocol.
77 c. The exception or appeal process of the health insurer
78 or pharmacy benefit manager.
79 (b) The amount paid by or on behalf of the insured which
80 is applied toward the insured's total contribution to any cost-
81 sharing requirement under paragraph (a) includes, but is not
82 limited to, any payment with or any discount throug h financial
83 assistance, a manufacturer copay card, a product voucher, or any
84 other reduction in out-of-pocket expenses made by or on behalf
85 of the insured for a prescription drug.
86 (3) This section applies to any health insurance policy
87 issued, delivered, or renewed in this state on or after January
88 1, 2025.
89 Section 2. Subsections (2) and (3) of section 627.6385,
90 Florida Statutes, are renumbered as subsections (3) and (4),
91 respectively, present subsection (2) of that section is amended,
92 and a new subsection (2) is added to that section, to read:
93 627.6385 Disclosures to policyholders; calculations of
94 cost sharing.—
95 (2) Each health insurer issuing, delivering, or renewing a
96 policy in this state which provides prescription drug coverage,
97 regardless of whether the prescription drug benefits are
98 administered or managed by the health insurer or by a pharmacy
99 benefit manager on behalf of the health insurer, shall disclose
100 on its website that any amount paid by a policyholder or by
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101 another person on behalf of the policyholder must be applied
102 toward the policyholder's total contribution to any cost -sharing
103 requirement pursuant to s. 627.6383. This subsection applies to
104 any policy issued, delivered, or renewed in this state on or
105 after January 1, 2025.
106 (3)(2) Each health insurer shall include in every policy
107 delivered or issued for delivery to any person in this the state
108 or in materials provided as required by s. 627.64725 a notice
109 that the information required by this section is available
110 electronically and the website address of the website where the
111 information can be accessed. In addition, each health insurer
112 issuing, delivering, or renewing a policy in this state which
113 provides prescription drug coverage, regardless of whether the
114 prescription drug benefits are administered or managed by the
115 health insurer or by a pharmacy benefit manager on behalf of the
116 health insurer, shall disclose in every policy that is issued,
117 delivered, or renewed to any person in this state on or after
118 January 1, 2025, that any amount paid by a policyholder or by
119 another person on behalf of the policyholder must be applied
120 toward the policyholder's total contribution to any cost -sharing
121 requirement pursuant to s. 627.6383.
122 Section 3. Paragraph (c) is added to subsection (2) of
123 section 627.64741, Florida Statutes, to read:
124 627.64741 Pharmacy benefit manager contracts.—
125 (2) In addition to the requirements of part VII of chapter
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126 626, a contract between a health insurer and a pharmacy benefit
127 manager must require that the pharmacy benefit manager:
128 (c)1. Apply any amount paid by an insured or by another
129 person on behalf of the insured toward the insured's total
130 contribution to any cost-sharing requirement pursuant to s.
131 627.6383. This subparagraph applies to any insured whose
132 insurance policy is issued, delivered, or renewed in this state
133 on or after January 1, 2025.
134 2. Disclose to every insured whose insurance policy is
135 issued, delivered, or renewed in this state on or after January
136 1, 2025, that the pharmacy benefit manager shall apply any
137 amount paid by the insured or by another person on behalf of the
138 insured toward the insured's total contribution to any cost-
139 sharing requirement pursuant to s. 627.6383.
140 Section 4. Section 627.65715, Florida Statutes, is create d
141 to read:
142 627.65715 Cost-sharing requirements.—
143 (1) As used in this section, the term "cost-sharing
144 requirement" means a dollar limit, a deductible, a copayment,
145 coinsurance, or any other out-of-pocket expense imposed on an
146 insured, including, but not limited to, the annual limitation on
147 cost sharing subject to 42 U.S.C. s. 18022.
148 (2)(a) Each insurer issuing, delivering, or renewing a
149 policy in this state which provides prescription drug coverage,
150 or each pharmacy benefit manager on behalf of such in surer,
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151 shall apply any amount paid for a prescription drug by an
152 insured or by another person on behalf of the insured toward the
153 insured's total contribution to any cost-sharing requirement, if
154 the prescription drug:
155 1. Does not have a generic equivalent; or
156 2. Has a generic equivalent and the insured has obtained
157 authorization for the prescription drug through any of the
158 following:
159 a. Prior authorization from the health insurer or pharmacy
160 benefit manager.
161 b. A step-therapy protocol.
162 c. The exception or appeal process of the health insurer
163 or pharmacy benefit manager.
164 (b) The amount paid by or on behalf of the insured which
165 is applied toward the insured's total contribution to any cost-
166 sharing requirement under paragraph (a) includes, but is not
167 limited to, any payment with or any discount through financial
168 assistance, a manufacturer copay card, a product voucher, or any
169 other reduction in out-of-pocket expenses made by or on behalf
170 of the insured for a prescription drug.
171 (3) Each insurer issuing, delivering, or renewing a policy
172 in this state which provides prescription drug coverage,
173 regardless of whether the prescription drug benefits are
174 administered or managed by the insurer or by a pharmacy benefit
175 manager on behalf of the insurer, shall disclose on its website
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176 and in every policy issued, delivered, or renewed in this state
177 on or after January 1, 2025, that any amount paid by an insured
178 or by another person on behalf of the insured must be applied
179 toward the insured's total contribution to any cost-sharing
180 requirement.
181 (4) This section applies to any group health insurance
182 policy issued, delivered, or renewed in this state on or after
183 January 1, 2025.
184 Section 5. Paragraph (c) is added to subsection (2) of
185 section 627.6572, Florida Statutes, to read:
186 627.6572 Pharmacy benefit manager contracts.—
187 (2) In addition to the requirements of part VII of chapter
188 626, a contract between a health insurer and a pharmacy benefit
189 manager must require that the pharmacy benefit manager:
190 (c)1. Apply any amount paid by an insured or by another
191 person on behalf of the insured toward the insured's total
192 contribution to any cost-sharing requirement pursuant to s.
193 627.65715. This subparagraph applies to any insured whose
194 insurance policy is issued, delivered, or renewed in this state
195 on or after January 1, 2025.
196 2. Disclose to every insured whose insurance policy is
197 issued, delivered, or renewed in this state on or after January
198 1, 2025, that the pharmacy benefit manager shall apply any
199 amount paid by the insured or by another person on behalf of the
200 insured toward the insured's total contribution to any cost-
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201 sharing requirement pursuant to s. 627.65715.
202 Section 6. Paragraph (e) of subsection (5) of section
203 627.6699, Florida Statutes, is amended to read:
204 627.6699 Employee Health Care Access Act.—
205 (5) AVAILABILITY OF COVERAGE.—
206 (e) All health benefit plans issued under this section
207 must comply with the following conditions:
208 1. For employers who have fewer than two employees, a late
209 enrollee may be excluded from coverage for no longer than 24
210 months if he or she was not covered by creditable coverage
211 continually to a date not more than 63 days before the effective
212 date of his or her new coverage.
213 2. Any requirement used by a small employer carrier in
214