Senate Bill 1878
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
By Senator Diaz de la Portilla
34-1480-00 See HB 611
1 A bill to be entitled
2 An act relating to elderly pharmaceutical
3 insurance coverage; providing a short title;
4 providing definitions; providing a program for
5 pharmaceutical insurance coverage for elderly
6 persons; providing for program eligibility;
7 providing for pharmaceutical insurance
8 contracts; providing criteria and requirements;
9 providing contractor responsibilities;
10 providing for contractor's reports;
11 establishing an elderly pharmaceutical
12 insurance coverage board; providing for
13 membership; providing duties of the board;
14 requiring reports; providing for an advisory
15 committee to the board; providing for
16 membership of the committee; providing for an
17 executive director of the board; providing for
18 a salary; providing duties of the executive
19 director; specifying program rule requirements;
20 providing dispensation limitations; providing
21 eligibility requirements for program
22 participants who qualify by paying an
23 application fee or meeting a deductible;
24 specifying the amount of the fee or deductible
25 for certain persons; providing for copayments;
26 providing for annual determinations by the
27 board of increases in covered amounts;
28 providing for participating provider
29 pharmacies; providing for reimbursement to
30 provider pharmacies; providing penalties for
31 fraud and abuse; providing procedures for
1
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 determinations by the Department of Health
2 relating to package or form of dosage or
3 administration of certain drugs as excluded
4 from the program as covered drugs; providing an
5 exception; providing for use of out of state
6 pharmacies; providing criteria and procedures;
7 providing an effective date.
8
9 Be It Enacted by the Legislature of the State of Florida:
10
11 Section 1. (1) SHORT TITLE.--This act may be cited as
12 the "Elderly Pharmaceutical Insurance Coverage Act".
13 (2) DEFINITIONS.--For purposes of this act, the term:
14 (a) "Annual coverage period" means the period of 12
15 consecutive calendar months for which an eligible program
16 participant has met the application fee or deductible
17 requirements of subsections (8) and (9).
18 (b) "Board" means the Elderly Pharmaceutical Insurance
19 Coverage Board established under subsection (5).
20 (c) "Contractor" means a private not-for-profit or
21 proprietary corporation that has entered into a contractual
22 arrangement with this state to carry out the provisions of
23 subsection (4).
24 (d) "Covered drug" means a drug dispensed subject to a
25 legally authorized prescription pursuant to chapter 465,
26 Florida Statutes, or chapter 893, Florida Statutes, and
27 insulin, an insulin syringe, or an insulin needle. Such term
28 does not include:
29 1. Any drug determined by the Commissioner of the
30 Federal Food and Drug Administration to be ineffective or
31 unsafe.
2
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 2. Any drug dispensed in a package, or form of dosage
2 or administration, which the Secretary of Health finally
3 determines pursuant to subsection (13) does not constitute a
4 covered drug for purposes of this act.
5 3. Any device for the aid or correction of vision or
6 any drug, including vitamins, which is generally available
7 without a physician's prescription.
8 (e) "Executive director" means the executive director
9 of the board established under subsection (5).
10 (f) "Income" means "adjusted gross income" as defined
11 in section 420.0004, Florida Statutes, but includes only the
12 income of program applicants and spouses and excludes the
13 income of other members of the household.
14 (g) "Provider pharmacy" means a pharmacy registered in
15 this state pursuant to chapter 465, Florida Statutes, or a
16 pharmacy registered in a state bordering this state when
17 certified as necessary by the executive director pursuant to
18 subsection (14), for which an agreement to provide pharmacy
19 services for purposes of the program pursuant to subsection
20 (10) is in effect.
21 (h) "Program year" means a year beginning on October 1
22 and ending the following September 30.
23 (i) "Resident" means an individual legally domiciled
24 within this state.
25 (j) "Secretary" means the secretary of the Department
26 of Health.
27 (3) PROGRAM ELIGIBILITY.--
28 (a) Persons eligible for coverage under subsection (8)
29 include:
30 1. Any unmarried resident who is at least 65 years of
31 age and whose income for the calendar year immediately
3
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 preceding the effective date of the annual coverage period is
2 less than or equal to $12,000.
3 2. Any married resident who is at least 65 years of
4 age and whose income for the calendar year immediately
5 preceding the effective date of the annual coverage period
6 when combined with the income in the same calendar year of
7 such married person's spouse is less than or equal to $15,000
8 dollars.
9
10 After the initial determination of eligibility, each eligible
11 individual must be redetermined eligible at least every 24
12 months.
13 (b) Persons eligible for coverage under subsection (9)
14 include:
15 1. Any unmarried resident who is at least 65 years of
16 age and whose income for the calendar year immediately
17 preceding the effective date of the annual coverage period is
18 more than $12,000 and less than $18,000.
19 2. Any married resident who is at least 65 years of
20 age and whose income for the calendar year immediately
21 preceding the effective date of the annual coverage period
22 when combined with the income in the same calendar year of
23 such married person's spouse is more than $15,000 and less
24 than $23,000.
25
26 After the initial determination of eligibility, each eligible
27 individual must be redetermined eligible at least every 24
28 months.
29 (c)1. Eligibility for assistance under this act shall
30 not be granted to any person who, at the time an application
31 is made, is receiving medical assistance under any other
4
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 provision of law of this state or to any person receiving
2 equivalent or better coverage from any other public or private
3 third-party payment source or insurance plan than those
4 benefits provided for under this act.
5 2. An individual who is determined eligible for
6 assistance under this act whose prescription costs are covered
7 in part by any public or private plan may receive reduced
8 assistance under this act. In such cases, benefits provided
9 through this act shall be considered payments of last resort.
10 3. The fact that some of an individual's prescription
11 drug expenses are paid or reimbursable under Medicare shall
12 not disqualify an individual, if he or she is otherwise
13 eligible, from receiving assistance under this act. In such
14 cases, the state shall pay the portion of the cost of those
15 prescriptions for qualified drugs for which no payment or
16 reimbursement is made by Medicare, less the participant's
17 copayment required on the amount not paid by Medicare.
18 (4) PHARMACEUTICAL INSURANCE CONTRACT.--
19 (a) The board established under subsection (5) shall,
20 subject to the approval of the Governor, enter into a contract
21 with one or more contractors to assist in carrying out the
22 provisions of this act. Such contractual arrangements shall
23 be made subject to a competitive bidding process and shall
24 ensure that state payments for the contractor's necessary and
25 legitimate expenses for the administration of this program are
26 limited to the amount specified in advance, and that such
27 payments shall not exceed the amount appropriated for such
28 expenses in any fiscal year. The board shall, at each of its
29 regularly scheduled meetings, review the contract pricing
30 provisions to assure that the level of contract payments are
31 in the best interest of the state, giving consideration to the
5
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 total level of participant enrollment achieved, the volume of
2 claims processed, and such other factors as may be relevant in
3 order to contain state expenditures. If the board determines
4 that the contract payment provisions do not protect the
5 interests of the state, the executive director shall initiate
6 contract negotiations for the purpose of modifying contract
7 payments or scope requirements.
8 (b) The responsibilities of any contractor shall
9 include, but need not be limited to:
10 1. Providing for a method of determining, on an annual
11 basis and upon application by any person, the eligibility of
12 persons pursuant to subsection (3) within a reasonable period
13 of time, including alternative methods for such determination
14 of eligibility, including, but not limited to, through the
15 mail or home visits, where reasonable or necessary, and for
16 notifying applicants of such eligibility determinations.
17 2. Notifying each eligible program participant in
18 writing prior to the commencement of the annual coverage
19 period of such participant's cost-sharing responsibilities
20 pursuant to subsections (8) and (9). The contractor shall
21 also notify each eligible program participant of any
22 adjustment of the copayment schedule by mail no less than 30
23 days prior to the effective date of such adjustment and shall
24 inform such eligible program participants of the date such
25 adjustment shall take effect.
26 3. Issuing an identification card to each program
27 participant who is eligible to purchase prescribed covered
28 drugs for an amount specified pursuant to paragraph (8)(c) or
29 paragraph (9)(c). Cards shall be issued to participants
30 meeting application fee or deductible requirements on or
31 before the effective date of the card. The dates of the annual
6
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 coverage period shall be printed on the card. When an eligible
2 program participant meets the annual limits on point of sale
3 copayments set forth in paragraph (8)(d) or paragraph (9)(d),
4 new identification cards shall be issued to such participant
5 indicating waiver of such copayment requirements for the
6 remainder of the annual coverage period or the contractor
7 shall develop and implement an alternative method to permit
8 the purchase of covered drugs without a copayment requirement.
9 Such participant shall be provided a means of recovering any
10 excess copayments made prior to their receipt of such new
11 identification cards or prior to the implementation of any
12 such alternative method.
13 4. Developing and implementing the system for those
14 individuals electing the deductible option to record their
15 personal covered drug expenditures in accordance with
16 paragraph (9)(c). Such recordkeeping system shall be provided
17 to each such participant at a nominal charge which shall be
18 subject to the approval of the board. The contractor shall
19 also reimburse participants for personal covered drug
20 expenditures made in excess of their deductible requirements,
21 less the copayments required by paragraph (9)(d), made prior
22 to their receipt of an identification card issued in
23 accordance with subparagraph 3.
24 5. Processing of claims for reimbursement to
25 participating provider pharmacies pursuant to subsection (11).
26 6. Performing or causing to be performed utilization
27 reviews for such purposes as may be required by the board.
28 7. Conducting audits and surveys of participating
29 provider pharmacies as specified pursuant to the terms and
30 conditions of the contract.
31
7
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 8. Coordinating coverage with insurance companies and
2 other public and private organizations offering such coverage
3 for those eligible program participants having partial
4 coverage for covered drugs through third-party sources, and
5 providing for recoupment of any duplicate reimbursement paid
6 by the state on behalf of such eligible program participants.
7 (c) The contractor or contractors shall be required to
8 provide such reports as may be deemed necessary by the board
9 and shall maintain files in a manner and format approved by
10 the executive director.
11 (d) The contractor or contractors may contract with
12 private not-for-profit or proprietary corporations, or with
13 entities of local government within this state, to perform
14 such obligations of the contractor or contractors as the board
15 shall permit.
16 (5) ELDERLY PHARMACEUTICAL INSURANCE COVERAGE BOARD.--
17 (a) The Elderly Pharmaceutical Insurance Coverage
18 Board is hereby established within the Executive Office of the
19 Governor.
20 (b) The board shall consist of the Commissioner of
21 Education, the Secretary of Health, the Insurance
22 Commissioner, the Secretary of Elderly Affairs, and the
23 Secretary of Management Services. Each board member may
24 designate an officer of his or her respective department to
25 represent and exercise all the powers of such board member as
26 the case may be at all meetings of the board from which such
27 board member may be absent.
28 (c) The Secretary of Elderly Affairs and Secretary of
29 Health shall serve as co-chairs of the board.
30
31
8
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 (d) The board shall meet at such times as may be
2 requested by the co-chairs, provided that the board shall meet
3 at least four times each year.
4 (e) The board shall:
5 1. Subject to the approval of the Governor, adopt
6 program rules pursuant to subsection (7).
7 2. Determine the annual schedule of cost-sharing
8 responsibilities of eligible program participants pursuant to
9 subsections (8) and (9).
10 3. Enter into contracts pursuant to subsection (4).
11 4. Recommend and implement alternative program
12 improvements for the efficient and effective operation of the
13 program in accordance with the provisions of this act.
14 5. Establish or contract for a therapeutic drug
15 monitoring program. Such program shall monitor therapeutic
16 drug use of eligible program participants in an effort to
17 prevent the incorrect or unnecessary consumption of such
18 therapeutic drugs.
19 6. Develop and implement, in cooperation with area
20 offices for the aging, an outreach program to inform the
21 elderly of benefits they may be entitled to pursuant to this
22 act and to make available information concerning the program
23 for elderly pharmaceutical insurance coverage.
24 7. Prepare an annual report and submit such report to
25 the Governor, the President of the Senate, and the Speaker of
26 the House of Representatives no later than the first day of
27 January of each year, beginning January 1, 2002. The board
28 shall include in the report a summary of the
29 administrative-cost-containment initiatives completed during
30 the year. Such report shall, at a minimum, contain annual
31 statistical information regarding the number of persons
9
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 enrolled in the program by marital status and income level;
2 the total and per capita number of prescriptions filled and
3 total state reimbursement and participant copayment
4 expenditures, by income levels; the total numbers of
5 prescriptions filled with generic drugs, brand name drugs, and
6 sole source drugs; the authorization and substitution rate for
7 the total numbers of prescriptions filled with generic, brand
8 name, and sole source drugs; the distribution of the top 300
9 most commonly used drugs by volume and cost; a distribution of
10 all prescriptions by volume and price; the annual percentage
11 increase in the cost of such drugs, numbers of participating
12 provider pharmacies, recipients, and payments by county; the
13 amount of cost recoveries for the period covered in the
14 report; projections of program costs for the following 2
15 years; and an evaluation of the performance of the program
16 contractor or contractors and of the cost-effectiveness of all
17 outreach efforts.
18 8. Prepare an evaluation report on the experience of
19 the program for the Governor, the President of the Senate, and
20 the Speaker of the House of Representatives no later than
21 October 1, 2001. Such report shall include the
22 recommendations of the board concerning the continuation of
23 the program.
24 (f) Board members shall receive no compensation for
25 their services as board members.
26 (g) There shall be an advisory committee to the board
27 comprised of twelve persons. Four members shall be appointed
28 by the Governor, three members shall be appointed by the
29 President of the Senate, one member shall be appointed by the
30 minority leader of the Senate, three members shall be
31 appointed by the Speaker of the House of Representatives, and
10
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 one member shall be appointed by the minority leader of the
2 House of Representatives. The committee members shall be
3 representatives of consumers, pharmacists, pharmaceutical drug
4 manufacturers, and pharmaceutical wholesalers. No less than
5 50 percent of the committee membership shall represent the
6 consumers of this state. The executive director shall consult
7 the advisory committee and consider its recommendations
8 concerning the implementation of this program and the policies
9 governing the continued operation of this program. Committee
10 members shall receive no compensation for their services but
11 shall be allowed their actual and necessary expenses incurred
12 in the performance of their duties.
13 (6) EXECUTIVE DIRECTOR.--Upon the recommendation of
14 the co-chairs, the Governor shall appoint an executive
15 director of the board. The executive director shall receive an
16 annual salary fixed by the Governor within the amount
17 available therefor by appropriation and shall be entitled to
18 reimbursement for reasonable expenses incurred in connection
19 with the performance of his or her duties. The executive
20 director shall:
21 (a) Monitor the provision of services pursuant to
22 contractual arrangements entered into pursuant to subsection
23 (4) and examine and review all documents and other information
24 to assure compliance with all provisions of this act, whether
25 such documents or other information are under the control of a
26 contractor or a participating provider pharmacy.
27 (b) Appoint staff and request the assistance of any
28 department or other agency of the state in performing such
29 functions as may be necessary to carry out the provisions of
30 this act.
31
11
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 (c) Perform such other functions as may be
2 specifically required by this act, as assigned by the board,
3 or necessary to ensure the efficient operation of the program.
4 (7) RULES.--
5 (a) The board shall adopt program rules that shall:
6 1. Provide for a process of determining and
7 redetermining eligibility for participation in the program,
8 including provisions for submission of proof of income, age,
9 and residency and information on existing complete or partial
10 coverage of prescription drug expenses under a third-party
11 assistance or insurance plan.
12 2. Provide for a fair-hearing process pursuant to an
13 agreement with the Department of Health for individuals and
14 participating provider pharmacies to appeal determinations or
15 actions of the contractors.
16 3. Establish procedures for the state to recover the
17 value of benefits or payments made under this act, if any,
18 which were based on applications or claims submitted in
19 violation of any provision of this act.
20 (b) For purposes of this act, except as otherwise
21 provided in this act, a covered drug shall be dispensed in
22 quantities no greater than a 30-day supply or 100 units,
23 whichever is greater. In the case of a drug dispensed in a
24 form of administration other than a tablet or capsule, the
25 maximum allowed quantity shall be a 30-day supply. The board
26 is authorized to approve exceptions to such limits for
27 specific products following consideration of recommendations
28 from pharmaceutical or medical experts regarding commonly
29 packaged quantities, unusual forms of administration, length
30 of treatment, or cost-effectiveness.
31
12
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 (8) ELIGIBILITY REQUIREMENTS FOR PARTICIPANTS
2 QUALIFYING BY PAYMENT OF AN APPLICATION FEE.--
3 (a) Each eligible individual meeting the application
4 fee requirements of this subsection may purchase covered drugs
5 for an amount specified by paragraph (c).
6 (b) An eligible individual electing to meet the
7 requirements of this subsection shall pay a one-time
8 application fee of $10 in a manner and form determined by the
9 executive director prior to the beginning of a participant's
10 first annual coverage period.
11 (c)1.a. Upon payment of the application fee pursuant
12 to paragraph (b), an eligible program participant shall, at
13 the time of each purchase of a covered drug, pay the lesser of
14 a point-of-sale copayment as set forth in sub-subparagraph b.
15 or the actual cost of the drug purchased. Such copayment shall
16 not be waived or reduced in whole or in part, subject to the
17 limits provided by paragraph (d).
18 b. The point-of-sale copayment amounts that are to be
19 charged eligible program participants shall be in accordance
20 with the following schedule:
21 (I) For each purchase of a covered drug costing $29.99
22 or less, $6.00.
23 (II) For each purchase of a covered drug costing
24 $30.00 or more, $15.00.
25
26 For the purposes of such schedule of point-of-sale copayments,
27 "costing" means the amount of reimbursement which shall be
28 paid by the state to a participating provider pharmacy in
29 accordance with subsection (11) plus the point-of-sale
30 copayment, calculated as of the date of sale.
31
13
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 2. Commencing October 1, 2001, and every year
2 thereafter, the board shall determine the percentage increase
3 in the average wholesale price per unit of medication for
4 approved claims for the top 500 drugs most commonly used
5 during the prior program year, weighted for volume of claims.
6 If the increase in the average wholesale price, as determined
7 by the board, is greater than the percentage increase in the
8 prescription drug component of the consumer price index
9 measured for the same period, the board may increase the
10 point-of-sale copayment per purchase of a covered drug set
11 forth in this subdivision, or the corresponding ranges of
12 program prices in effect at the time such adjustment is made,
13 or both, by an amount not to exceed the lesser of the
14 percentage increase in:
15 a. The average wholesale price per unit weighted for
16 volume of claim approved during the previous program year; or
17 b. The prescription drug component of the consumer
18 price index during the previous program year.
19
20 The determination to increase the amount of point of sale
21 copayments or corresponding range of program prices in effect
22 shall follow a review of such factors as the relative
23 financial capacity of the state and such eligible program
24 participants to support such adjustments and changes in the
25 cost-of-living adjustment made in social security benefits.
26 Such increase shall not take effect sooner than 60 days after
27 the board makes such determination. Notwithstanding any
28 inconsistent provision of this subparagraph, the board may
29 adjust the point-of-sale copayment schedule to reflect the
30 relative financial capacity of the state, and in no event
31 shall such adjustment reduce the state share of the cost of
14
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 covered drugs at the time of purchase to an average amount of
2 less than 65 percent.
3 (d) During each annual coverage period, no
4 point-of-sale copayment as set forth in paragraph (c) shall be
5 required to be made for the remainder of such period by any
6 eligible program participant who has already incurred
7 copayments in excess of the following limits:
8 1. On copayments by an unmarried individual who is an
9 eligible program participant:
10 a. Individual income of $5,000 or less, no more than
11 $400.
12 b. Individual income of $5,001 to $6,000, no more than
13 $480.
14 c. Individual income of $6,001 to $7,000, no more than
15 $560.
16 d. Individual income of $7,001 to $8,000, no more than
17 $640.
18 e. Individual income of $8,001 to $9,000, no more than
19 $720.
20 f. Individual income of $9,001 to $10,000, no more
21 than $800.
22 g. Individual income of $10,001 to $11,000, no more
23 than $880.
24 h. Individual income of $11,001 to $12,000, no more
25 than $960.
26 2. On copayments by each married individual who is an
27 eligible program participant:
28 a. Joint income of $5,000 or less, no more than $300.
29 b. Joint income of $5,001 to $6,000, no more than
30 $360.
31
15
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 c. Joint income of $6,001 to $7,000, no more than
2 $420.
3 d. Joint income of $7,001 to $8,000, no more than
4 $480.
5 e. Joint income of $8,001 to $9,000, no more than
6 $540.
7 f. Joint income of $9,001 to $10,000, no more than
8 $600.
9 g. Joint income of $10,001 to $11,000, no more than
10 $660.
11 h. Joint income of $11,001 to $12,000, no more than
12 $720.
13 i. Joint income of $12,001 to $13,000, no more than
14 $780.
15 j. Joint income of $13,001 to $14,000, no more than
16 $840.
17 k. Joint income of $14,001 to $15,000, no more than
18 $900.
19 (9) ELIGIBILITY REQUIREMENT FOR PARTICIPANTS
20 QUALIFYING BY MEETING A DEDUCTIBLE.--
21 (a) Each eligible individual meeting the deductible
22 requirements of this subsection may purchase covered drugs for
23 an amount specified by paragraph (c).
24 (b) Each eligible individual approved for coverage
25 under this subsection who shall incur during any annual
26 coverage period $150 of personal covered drug expenditures
27 that are not reimbursed by any other public or private
28 third-party payment source or insurance plan shall be deemed
29 to have met his or her deductible requirements for the
30 remainder of such annual coverage period.
31
16
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 (c)1.a. Upon satisfaction of the deductible
2 requirements of paragraph (b), an eligible program participant
3 shall, at the time of each purchase of a covered drug, pay the
4 lesser of a point-of-sale copayment as set forth in
5 sub-subparagraph b. or the actual cost of the drug purchased.
6 Such copayment shall not be waived or reduced in whole or in
7 part, subject to the limits provided by paragraph (d).
8 b. The point-of-sale copayment amounts that are to be
9 charged eligible program participants shall be in accordance
10 with the following schedule:
11 (I) For each purchase of a covered drug costing $29.99
12 or less, $6.
13 (II) For each purchase of a covered drug costing $30
14 or more, $15.
15
16 For purposes of such schedule, "costing" means the amount of
17 reimbursement which shall be paid by the state to a
18 participating provider pharmacy in accordance with subsection
19 (11) plus the point-of-sale copayment, calculated as of the
20 date of sale.
21 2. Commencing October 1, 2001, and every year
22 thereafter, the board shall determine the percentage increase
23 in the average wholesale price per unit of medication for
24 approved claims for the top 500 drugs most commonly used
25 during the prior program year, weighted for volume of claims.
26 If the increase in the average wholesale price, as determined
27 by the board, is greater than the percentage increase in the
28 prescription drug component of the consumer price index
29 measured for the same period, the board may increase the point
30 of sale copayment per purchase of a covered drug set forth in
31 this paragraph, or the corresponding ranges of program prices
17
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 in effect at the time such adjustment is made, or both, by an
2 amount not to exceed the lesser of the percentage increase in:
3 a. The average wholesale price per unit weighted for
4 volume of claims approved during the previous program year; or
5 b. The prescription drug component of the consumer
6 price index during the previous program year.
7
8 The determination to increase the amount of point-of-sale
9 copayments or corresponding range of program prices in effect
10 shall follow a review of such factors as the relative
11 financial capacity of this state and such eligible program
12 participants to support such adjustments and changes in the
13 cost-of-living adjustment made in social security benefits.
14 Such increase shall not take effect sooner than 60 days after
15 the board makes such determination. Notwithstanding any
16 inconsistent provision of this subparagraph, the board may
17 adjust the point-of-sale copayment schedule to reflect the
18 relative financial capacity of the state, and in no event
19 shall such adjustment reduce the state share of the cost of
20 covered drugs at the time of purchase to an average amount of
21 less than 65 percent.
22 (d) During each annual coverage period, no
23 point-of-sale copayments as set forth in paragraph (c) shall
24 be required to be made for the remainder of such period by any
25 eligible program participant meeting the personal covered drug
26 expenditure requirements of paragraph (b) in excess of the
27 following limits:
28 1. On copayments by each unmarried individual who is
29 an eligible program participant:
30 a. Individual income of $10,000 or less, no more than
31 $575.
18
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 b. Individual income of $10,001 to $11,000, no more
2 than $633.
3 c. Individual income of $11,001 to $12,000, no more
4 than $690.
5 d. Individual income of $12,001 to $13,000, no more
6 than $748.
7 e. Individual income of $13,001 to $14,000, no more
8 than $805.
9 f. Individual income of $14,001 to $15,000, no more
10 than $863.
11 g. Individual income of $15,001 to $16,000, no more
12 than $920.
13 h. Individual income of $16,001 to $17,000, no more
14 than $978.
15 i. Individual income of $17,001 to $18,000, no more
16 than $1035.
17 2. On copayments by each married individual who is an
18 eligible program participant:
19 a. Joint income of $13,000 or less, no more than $561.
20 b. Joint income of $13,001 to $14,000, no more than
21 $603.50.
22 c. Joint income of $14,001 to $15,000, no more than
23 $647.
24 d. Joint income of $15,001 to $16,000, no more than
25 $690.
26 e. Joint income of $16,001 to $17,000, no more than
27 $733.
28 f. Joint income of $17,001 to $18,000, no more than
29 $776.50.
30 g. Joint income of $18,001 to $19,000, no more than
31 $819.50.
19
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 h. Joint income of $19,001 to $20,000, no more than
2 $862.50.
3 i. Joint income of $20,001 to $21,000, no more than
4 $906.
5 j. Joint income of $21,001 to $22,000, no more than
6 $949.
7 k. Joint income of $22,001 to $23,000, no more than
8 $992.
9 (10) PARTICIPATING PROVIDER PHARMACIES.--
10 (a) The state shall offer an opportunity to
11 participate in this program to all pharmacies as defined in
12 subsection (2).
13 (b) To participate in this program, a pharmacy shall
14 be required to enter into a provider agreement and shall abide
15 by such terms and conditions as shall be prescribed in the
16 agreement, including the release of financial information for
17 the purpose of program audits and surveys.
18 (11) REIMBURSEMENT TO PARTICIPATING PROVIDER
19 PHARMACIES.--
20 (a) The amount of reimbursement which shall be paid by
21 the state to a participating provider pharmacy for any covered
22 drug filled or refilled for any eligible program participant
23 shall be equal to the lower of:
24 1. The usual and customary charge of the pharmacy for
25 such drugs minus the point-of-sale copayment as required by
26 subsections (8) and (9);
27 2. The pharmacy's charge to the general public at the
28 time of purchase, taking into consideration any quantity and
29 promotional discounts, minus the point-of-sale copayment as
30 required by subsections (8) and (9); or
31
20
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 3. The average wholesale price based on the quantities
2 participating pharmacies buy most frequently, provided such
3 average wholesale prices shall be discounted by 5 percent for
4 any participating provider pharmacy or group of provider
5 pharmacies with common ownership whose total prescription
6 volume for the preceding calendar year was at least 100,000
7 prescriptions dispensed,
8
9 plus a dispensing fee of $2.75, except that such dispensing
10 fee shall be $3 for participating provider pharmacies that
11 provide 24-hour emergency prescription service, emergency
12 delivery service at no cost to the consumer, and direct
13 patient consultation with each prescription and that maintain
14 a patient drug profile card on each eligible program
15 participant, and minus the point-of-sale copayment as required
16 by subsections (8) and (9).
17 (b) For purposes of determining the amount of
18 reimbursement which shall be paid to a participating provider
19 pharmacy, the board shall determine or cause to be determined,
20 through a statistically valid survey, the quantities of each
21 covered drug which participating provider pharmacies buy most
22 frequently. Using the results of such survey, the contractor
23 shall update every 30 days the list of average wholesale
24 prices upon which such reimbursement is determined, using
25 nationally recognized and most recently revised sources. Such
26 price revisions shall be made available to all participating
27 provider pharmacies. The pharmacist shall be reimbursed based
28 on the price in effect at the time the covered drug is
29 dispensed.
30 (c)1. Notwithstanding any inconsistent provision of
31 law, if a manufacturer, as defined in s. 1927 of the Federal
21
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 Social Security Act, has entered into a rebate agreement with
2 the Department of Health or with the Federal Secretary of
3 Health and Human Services on behalf of the Department of
4 Health under s. 1927 of the Federal Social Security Act, the
5 program for elderly pharmaceutical insurance coverage shall
6 reimburse for covered drugs that are dispensed under the
7 program by a provider pharmacy only pursuant to the terms of
8 the rebate agreement between the program and such
9 manufacturer; however, the program may reimburse for any
10 covered drugs pursuant to paragraphs (a) and (b) which are
11 rated 1-A by the Federal Food and Drug Administration and
12 which are determined by the board to be essential to the
13 health of persons participating in the program.
14 2. The rebate agreement between such manufacturer and
15 the program for elderly pharmaceutical insurance coverage
16 shall use for covered single-source drugs and innovator
17 multiple-source drugs the identical formula used to determine
18 the basic rebate for federal financial participation for
19 single-source drugs and innovator multiple-source drugs,
20 pursuant to s. 1927(c)(1) of the Federal Social Security Act,
21 to determine the amount of the rebate pursuant to this
22 paragraph. The rebate agreement between such manufacturer and
23 the program for elderly pharmaceutical insurance coverage
24 shall use for non-innovator multiple-source drugs, the
25 identical formula used to determine the basic rebate for
26 federal financial participation for non-innovator
27 multiple-source drugs, pursuant to s. 1927(c)(3) of the
28 Federal Social Security Act, to determine the amount of the
29 rebate pursuant to this subparagraph. The amount of rebate
30 shall be calculated by multiplying the required rebate
31 formulas by the total number of units of each dosage form and
22
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 strength dispensed. The rebate agreement shall also provide
2 for periodic payment of the rebate, provision of information
3 to the program, audits, verification of data, and
4 confidentiality of information.
5 3. The program, in providing utilization data to a
6 manufacturer as provided for under s. 1927(b) of the Federal
7 Social Security Act, shall provide such data by zip code, if
8 requested, for the top 300 most commonly used drugs by volume
9 covered under a rebate agreement.
10 4. Any funds collected pursuant to any rebate
11 agreements entered into with a manufacturer pursuant to this
12 paragraph shall be deposited into the General Revenue Fund.
13 (12) PENALTIES FOR FRAUD AND ABUSE.--
14 (a) Any person who knowingly makes a false statement
15 or representation, or who, by deliberate concealment of any
16 material fact or by impersonation or other fraudulent device,
17 obtains or attempts to obtain or aids or abets any person to
18 obtain any benefit under this act to which he or she is not
19 entitled, commits a misdemeanor of the first degree,
20 punishable as provided in section 775.082 or section 775.083,
21 Florida Statutes.
22 (b) Any person who, having made application to receive
23 any benefit under this act for the use and benefit of another
24 and having received such benefit, knowingly and willfully
25 converts such benefit or any part of such benefit to a use
26 other than for the use and benefit of such other person
27 commits a misdemeanor of the first degree, punishable as
28 provided in section 775.082 or section 775.083, Florida
29 Statutes.
30 (c) Any person who, with intent to defraud, presents
31 for allowance or payment any false or fraudulent claim for
23
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 furnishing services or merchandise, or knowingly submits false
2 information for the purpose of obtaining greater compensation
3 than that to which such person is legally entitled for
4 furnishing services or merchandise, or knowingly submits false
5 information for the purpose of obtaining authorization for
6 furnishing services or merchandise under this act commits a
7 misdemeanor of the first degree, punishable as provided in
8 section 775.082 or section 775.083, Florida Statutes.
9 (13) PROCEDURES FOR DETERMINATIONS RELATING TO
10 PACKAGE, OR FORM OF DOSAGE OR ADMINISTRATION, OF CERTAIN
11 DRUGS.--
12 (a) If the Secretary of Health makes an initial
13 determination that a particular package, or form of dosage or
14 administration, of a drug does not constitute a covered drug
15 for purposes of this act due to the availability of a less
16 expensive package, or form of dosage or administration, that
17 is pharmaceutically equivalent and equivalent in its
18 therapeutic effect for the general health characteristics of
19 the eligible program participant population, the department
20 shall notify the manufacturer of such drug product that the
21 department intends to exclude such package, or form of dosage
22 or administration, from the program and shall provide such
23 manufacturer with the reasons for such exclusion together with
24 the facts that the department relies upon to support its
25 initial determination. The manufacturer shall have 15 days
26 after receiving such exclusion notice to notify the department
27 of an intent to appeal the decision. If the manufacturer fails
28 to notify the department of an intent to appeal within the
29 time specified in this subsection, the Secretary of Health
30 shall immediately thereafter determine whether the package, or
31 form of dosage or administration, shall be excluded from the
24
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 program. If the manufacturer notifies the department of an
2 intent to appeal, the manufacturer shall submit to the
3 department, within 45 days after receiving such exclusion
4 notice, the basis of the manufacturer's appeal. Within 15 days
5 after receiving such submission from the manufacturer, the
6 department shall provide to the manufacturer any additional
7 facts concerning the drug product which the department relies
8 upon to support its initial determination. Within 10 days
9 after receiving such facts, the manufacturer may submit
10 additional facts concerning the drug package, or form of
11 dosage or administration. Based on the facts submitted
12 pursuant to this subsection, the Secretary of Health shall
13 make a final determination as to whether or not the package,
14 or form of dosage or administration, of the drug product
15 constitutes a covered drug for the purposes of this act. A
16 determination that a drug package, or form of dosage or
17 administration, does not constitute a covered drug for
18 purposes of this act is subject to judicial review.
19 (b) Notwithstanding paragraph (a), the Department of
20 Health shall establish by rule an appropriate process for
21 allowing drug packages, or forms of dosage or administration,
22 finally determined under this subsection not to be covered
23 drugs for the purposes of this act to be dispensed to program
24 participants for whom such drug packages, or forms of dosage
25 or administration, are medically indicated as certified to by
26 a physician treating such participant. Any such drug package,
27 or form of dosage or administration, so certified as medically
28 indicated for a specific participant in accordance with such
29 rules shall be a covered drug for the purpose of this act.
30 (14) USE OF OUT-OF-STATE PROVIDER PHARMACIES;
31 NECESSITY AND CONVENIENCE.--
25
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 (a) In counties having a population of 75,000 or less
2 which are in close proximity to Alabama or Georgia and which
3 are determined by the executive director to be inadequately
4 served by provider pharmacies registered in this state, the
5 executive director may approve as provider pharmacies,
6 pharmacies located in Alabama or Georgia. Such approvals may
7 be made only after:
8 1. Consideration of the convenience and necessity of
9 residents of this state in the rural areas served by such
10 pharmacies.
11 2. Consideration of the quality of service of such
12 pharmacies and the standing of such pharmacies with the
13 governmental board or agency of the state in which the
14 pharmacy is located.
15 3. The executive director has given all licensed
16 pharmacies within the county notice of his intention to
17 approve such out-of-state provider pharmacies.
18 4. The executive director has held a public hearing at
19 which he or she has determined factually that the licensed
20 pharmacies within such county are not adequately serving as
21 provider pharmacies.
22 (b) The executive director shall investigate and
23 determine within 90 days after the filing of an application
24 for certification by the governing body of any municipality
25 claiming to be lacking adequate pharmaceutical service within
26 a county determined by the executive director to be not
27 adequately served by provider pharmacies registered in this
28 state pursuant to paragraph (a) whether to grant
29 certification.
30
31
26
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 2000 SB 1878
34-1480-00 See HB 611
1 (c) Each certification granted pursuant to this
2 subsection shall expire not more than 5 years after its date
3 of issuance.
4 Section 2. This act shall take effect October 1, 2000.
5
6 *****************************************
7 LEGISLATIVE SUMMARY
8
Provides a program for pharmaceutical insurance coverage
9 for elderly persons. Provides for eligibility,
pharmaceutical insurance contracts, an elderly
10 pharmaceutical insurance coverage board and an advisory
committee to the board, program requirements, eligibility
11 requirements for program participants, participating
provider pharmacies, penalties for fraud and abuse,
12 procedures for determinations by the Department of Health
relating to package or form of dosage or administration
13 of drugs as excluded drugs, and use of out-of-state
pharmacies. (See bill for details.)
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
27