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 1543 2024
1 A bill to be entitled
2 An act relating to prescription drug coverage;
3 creating s. 627.42394, F.S.; requiring individual and
4 group health insurers to provide notice of
5 prescription drug formulary changes within a certain
6 timeframe to current and prospective insureds and the
7 insureds' treating physicians; specifying requirements
8 for the content of such notice and the manner in which
9 it must be provided; specifying requirements for a
10 notice of medical necessity submitted by the treating
11 physician; authorizing insurers to provide certain
12 means for submitting the notice of medical necessity;
13 requiring the Financial Services Commission to adopt a
14 certain form by rule by a specified date; specifying a
15 coverage requirement and restrictions on coverage
16 modification by insurers receiving a notice of medical
17 necessity; providing construction and applicability;
18 requiring insurers to maintain a record of formulary
19 changes; requiring insurers to annually submit a
20 specified report to the Office of Insurance Regulation
21 by a specified date; requiring the office to annually
22 compile certain data and prepare a report, make the
23 report publicly accessible on its website, and submit
24 the report to the Governor and the Legislature by a
25 specified date; amending s. 627.6699, F.S.; requiring
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26 small employer carriers to comply with certain
27 requirements for prescription drug formulary changes;
28 amending s. 641.31, F.S.; providing an exception to
29 requirements relating to changes in a health
30 maintenance organization's group contract; requiring
31 health maintenance organizations to provide notice of
32 prescription drug formulary changes within a certain
33 timeframe to current and prospective subscribers and
34 the subscribers' treating physicians; specifying
35 requirements for the content of such notice and the
36 manner in which it must be provided; specifying
37 requirements for a notice of medical necessity
38 submitted by the treating physician; authorizing
39 health maintenance organizations to provide certain
40 means for submitting the notice of medical necessity;
41 requiring the commission to adopt a certain form by
42 rule by a specified date; specifying a coverage
43 requirement and restrictions on coverage modification
44 by health maintenance organizations receiving a notice
45 of medical necessity; providing construction and
46 applicability; requiring health maintenance
47 organizations to maintain a record of formulary
48 changes; requiring health maintenance organizations to
49 annually submit a specified report to the office by a
50 specified date; requiring the office to annually
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51 compile certain data and prepare a report, make the
52 report publicly accessible on its website, and submit
53 the report to the Governor and the Legislature by a
54 specified date; providing applicability; providing a
55 declaration of important state interest; providing an
56 effective date.
57
58 Be It Enacted by the Legislature of the State of Florida:
59
60 Section 1. Section 627.42394, Florida Statutes, is created
61 to read:
62 627.42394 Health insurance policies; changes to
63 prescription drug formularies; requirements.—
64 (1) At least 60 days before the effective date of any
65 change to a prescription drug formulary during a policy year, an
66 insurer issuing individual or group health insurance policies in
67 the state shall notify:
68 (a) Current and prospective insureds of the change in the
69 formulary in a readily accessible format on the insurer's
70 website; and
71 (b) Any insured currently receiving coverage for a
72 prescription drug for which the formulary change modifies
73 coverage and the insured's treating physician. Such notification
74 must be sent electronically and by first-class mail and must
75 include information on the specific drugs involved and a
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76 statement that the submission of a notice of medical necessity
77 by the insured's treating physician to the insurer at least 30
78 days before the effective date of the formulary change will
79 result in continuation of coverage at the existing level.
80 (2) The notice provided by the treating physician to the
81 insurer must include a completed one-page form in which the
82 treating physician certifies to the insurer that th e
83 prescription drug for the insured is medically necessary as
84 defined in s. 627.732(2). The treating physician shall submit
85 the notice electronically or by first-class mail. The insurer
86 may provide the treating physician with access to an electronic
87 portal through which the treating physician may electronically
88 submit the notice. By January 1, 2025, the commission shall
89 adopt by rule a form for the notice.
90 (3) If the treating physician certifies to the insurer in
91 accordance with subsection (2) that the prescription drug is
92 medically necessary for the insured, the insurer:
93 (a) Must authorize coverage for the prescribed drug until
94 the end of the policy year, based solely on the treating
95 physician's certification that the drug is medically necessary;
96 and
97 (b) May not modify the coverage related to the covered
98 drug during the policy year by:
99 1. Increasing the out-of-pocket costs for the covered
100 drug;
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101 2. Moving the covered drug to a more restrictive tier;
102 3. Denying an insured coverage of the drug for which the
103 insured has been previously approved for coverage by the
104 insurer; or
105 4. Limiting or reducing coverage of the drug in any other
106 way, including subjecting it to a new prior authorization or
107 step-therapy requirement.
108 (4) Subsections (1), (2), and (3) do not:
109 (a) Prohibit the addition of prescription drugs to the
110 list of drugs covered under the policy during the policy year.
111 (b) Apply to a grandfathered health plan as defined in s.
112 627.402 or to benefits specified in s. 627.6513(1)-(14).
113 (c) Alter or amend s. 465.025, which provides conditions
114 under which a pharmacist may substitute a generically equivalent
115 drug product for a brand name drug product.
116 (d) Alter or amend s. 465.0252, which provides conditions
117 under which a pharmacist may dispense a substitute biological
118 product for the prescribed biological product.
119 (e) Apply to a Medicaid managed care plan under part IV of
120 chapter 409.
121 (5) A health insurer shall maintain a record of any change
122 in its formulary during a calendar year. By March 1 of each
123 year, a health insurer shall submit to the office a report
124 delineating such changes made in the previous calendar year. The
125 annual report must include, at a minimum:
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126 (a) A list of all drugs removed from the formulary and the
127 reasons for the removal;
128 (b) A list of all drugs moved to a tier resulting in
129 additional out-of-pocket costs to insureds;
130 (c) The number of insureds notified by the insurer of a
131 change in the formulary; and
132 (d) The increased cost, by dollar amount, incurred by
133 insureds because of such change in the formulary.
134 (6) By May 1 of each year, the office shall:
135 (a) Compile the data in the annual reports submitted by
136 health insurers under subsection (5) and prepare a report
137 summarizing the data submitted;
138 (b) Make the report publicly accessible on its website;
139 and
140 (c) Submit the report to the Governor, the President of
141 the Senate, and the Speaker of the House of Representatives.
142 Section 2. Paragraph (e) of subsection (5) of section
143 627.6699, Florida Statutes, is amended to read:
144 627.6699 Employee Health Care Access Act.—
145 (5) AVAILABILITY OF COVERAGE.—
146 (e) All health benefit plans issued under this section
147 must comply with the following conditions:
148 1. For employers who have fewer than two employees, a late
149 enrollee may be excluded from coverage for no longer than 24
150 months if he or she was not covered by creditable coverage
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151 continually to a date not more than 63 days before the effective
152 date of his or her new coverage.
153 2. Any requirement used by a small employer carrier in
154 determining whether to provide coverage to a small employer
155 group, including requirements for minimum participation of
156 eligible employees and minimum employer contributions, must be
157 applied uniformly among all small employer groups having the
158 same number of eligible employees applying for coverage or
159 receiving coverage from the small employer carrier, except that
160 a small employer carrier that participates in, administers, or
161 issues health benefits pursuant to s. 381.0406 which do not
162 include a preexisting condition exclusion may require as a
163 condition of offering such benefits that the employer has had no
164 health insurance coverage for its employees for a period of at
165 least 6 months. A small employer carrier may vary application of
166 minimum participation requirements and minimum employer
167 contribution requirements only by the size of the small employer
168 group.
169 3. In applying minimum participation requirements with
170 respect to a small employer, a small employer carrier shall not
171 consider as an eligible employee employees or dependents who
172 have qualifying existing coverage in an employer-based group
173 insurance plan or an ERISA qualified self-insurance plan in
174 determining whether the applicable percentage of participation
175 is met. However, a small employer carrier may count eligible
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176 employees and dependents who have coverage under another health
177 plan that is sponsored by that employer.
178 4. A small employer carrier shall not increase any
179 requirement for minimum employee participation or any
180 requirement for minimum employer contribution applicable to a
181 small employer at any time after the small employer has been
182 accepted for coverage, unless the employer size has changed, in
183 which case the small employer carrier may apply the requirements
184 that are applicable to the new group size.
185 5. If a small employer carrier offers coverage to a small
186 employer, it must offer coverage to all the small employer's
187 eligible employees and their dependents. A small employer
188 carrier may not offer coverage limited to certain persons in a
189 group or to part of a group, except with respect to late
190 enrollees.
191 6. A small employer carrier may not modify any health
192 benefit plan issued to a small employer with respect to a small
193 employer or any eligible employee or dependent throug h riders,
194 endorsements, or otherwise to restrict or exclude coverage for
195 certain diseases or medical conditions otherwise covered by the
196 health benefit plan.
197 7. An initial enrollment period of at least 30 days must
198 be provided. An annual 30-day open enrollment period must be
199 offered to each small employer's eligible employees and their
200 dependents. A small employer carrier must provide special
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201 enrollment periods as required by s. 627.65615.
202 8. A small employer carrier shall comply with s. 627.42394
203 for any change to a prescription drug formulary.
204 Section 3. Subsection (36) of section 641.31, Florida
205 Statutes, is amended to read:
206 641.31 Health maintenance contracts.—
207 (36) Except as provided in paragraphs (a), (b), and (c), a
208 health maintenance organization may increase the copayment for
209 any benefit, or delete, amend, or limit any of the benefits to
210 which a subscriber is entitled under the group contract only,
211 upon written notice to the contract holder at least 45 days in
212 advance of the time of coverage renewal. The health maintenance
213 organization may amend the contract with the contract holder,
214