House Bill 0611
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Florida House of Representatives - 2000 HB 611
By Representative Rojas
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
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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:
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 which 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.
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1 2. Any drug dispensed in a package, or form of dosage
2 or administration, as to 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 s. 420.0004, Florida Statutes, but includes only the income
12 of program applicants and spouses and excludes the income of
13 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
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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
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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
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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
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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.
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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.
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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 administrative
29 cost containment initiatives completed during the year. Such
30 report shall, at a minimum, contain annual statistical
31 information regarding the number of persons enrolled in the
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1 program by marital status and income level; the total and per
2 capita number of prescriptions filled and total state
3 reimbursement and participant copayment expenditures, by
4 income levels; the total numbers of prescriptions filled with
5 generic drugs, brand name drugs, and sole source drugs; the
6 authorization and substitution rate for the total numbers of
7 prescriptions filled with generic, brand name, and sole source
8 drugs; the distribution of the top 300 most commonly used
9 drugs by volume and cost; a distribution of all prescriptions
10 by volume and price; the annual percentage increase in the
11 cost of such drugs, numbers of participating provider
12 pharmacies, recipients, and payments by county; the amount of
13 cost recoveries for the period covered in the report;
14 projections of program costs for the following 2 years; and an
15 evaluation of the performance of the program contractor or
16 contractors and of the cost effectiveness of all outreach
17 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
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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.
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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 which 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 that 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.
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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 which 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.
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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 point
10 of sale copayment per purchase of a covered drug set forth in
11 this subdivision, or the corresponding ranges of program
12 prices in effect at the time such adjustment is made, or both,
13 by an amount not to exceed the lesser of the percentage
14 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
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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 point of
4 sale copayment as set forth in paragraph (c) shall be required
5 to be made for the remainder of such period by any eligible
6 program participant who has already incurred copayments in
7 excess of the following limits:
8 1. On copayments by unmarried individuals who are
9 eligible program participants:
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 eligible
27 program participants:
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.
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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 which 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.
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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 of copayment amounts which are to
9 be charged eligible program participants shall be in
10 accordance with the following schedule:
11 (I) For each purchase of a covered drug costing $29.99
12 or less, $6.00.
13 (II) For each purchase of a covered drug costing
14 $30.00 or more, $15.00.
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
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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 point of
23 sale copayments as set forth in paragraph (c) shall be
24 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 unmarried individual eligible
29 program participants:
30 a. Individual income of $10,000 or less, no more than
31 $575.
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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 eligible
18 program participant:
19 a. Joint income of $13,000 or less, no more than
20 $561.00.
21 b. Joint income of $13,001 to $14,000, no more than
22 $603.50.
23 c. Joint income of $14,001 to $15,000, no more than
24 $647.00.
25 d. Joint income of $15,001 to $16,000, no more than
26 $690.00.
27 e. Joint income of $16,001 to $17,000, no more than
28 $733.00.
29 f. Joint income of $17,001 to $18,000, no more than
30 $776.50.
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1 g. Joint income of $18,001 to $19,000, no more than
2 $819.50.
3 h. Joint income of $19,001 to $20,000, no more than
4 $862.50.
5 i. Joint income of $20,001 to $21,000, no more than
6 $906.00.
7 j. Joint income of $21,001 to $22,000, no more than
8 $949.00.
9 k. Joint income of $22,001 to $23,000, no more than
10 $992.00.
11 (10) PARTICIPATING PROVIDER PHARMACIES.--
12 (a) The state shall offer an opportunity to
13 participate in this program to all pharmacies as defined in
14 subsection (2).
15 (b) To participate in this program, a pharmacy shall
16 be required to enter into a provider agreement and shall abide
17 by such terms and conditions as shall be prescribed in the
18 agreement, including the release of financial information for
19 the purpose of program audits and surveys.
20 (11) REIMBURSEMENT TO PARTICIPATING PROVIDER
21 PHARMACIES.--
22 (a) The amount of reimbursement which shall be paid by
23 the state to a participating provider pharmacy for any covered
24 drug filled or refilled for any eligible program participant
25 shall be equal to the lower of:
26 1. The usual and customary charge of the pharmacy for
27 such drugs minus the point-of-sale copayment as required by
28 subsections (8) and (9);
29 2. The pharmacy's charge to the general public at the
30 time of purchase, taking into consideration any quantity and
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1 promotional discounts, minus the point-of-sale copayment as
2 required by subsections (8) and (9); or
3 3. The average wholesale price based on the quantities
4 participating pharmacies buy most frequently, provided such
5 average wholesale prices shall be discounted by 5 percent for
6 any participating provider pharmacy or group of provider
7 pharmacies with common ownership whose total prescription
8 volume for the preceding calendar year was at least 100,000
9 prescriptions dispensed,
10
11 plus a dispensing fee of $2.75, except that such dispensing
12 fee shall be $3 for participating provider pharmacies which
13 provide 24-hour emergency prescription service, emergency
14 delivery service at no cost to the consumer, and direct
15 patient consultation with each prescription and maintain a
16 patient drug profile card on each eligible program
17 participant, and minus the point-of-sale copayment as required
18 by subsections (8) and (9).
19 (b) For purposes of determining the amount of
20 reimbursement which shall be paid to a participating provider
21 pharmacy, the board shall determine or cause to be determined,
22 through a statistically valid survey, the quantities of each
23 covered drug that participating provider pharmacies buy most
24 frequently. Using the results of such survey, the contractor
25 shall update every 30 days the list of average wholesale
26 prices upon which such reimbursement is determined using
27 nationally recognized and most recently revised sources. Such
28 price revisions shall be made available to all participating
29 provider pharmacies. The pharmacist shall be reimbursed based
30 on the price in effect at the time the covered drug is
31 dispensed.
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1 (c)1. Notwithstanding any inconsistent provision of
2 law, if a manufacturer, as defined in s. 1927 of the Federal
3 Social Security Act, has entered into a rebate agreement with
4 the Department of Health or with the Federal Secretary of
5 Health and Human Services on behalf of the Department of
6 Health under s. 1927 of the Federal Social Security Act, the
7 program for elderly pharmaceutical insurance coverage shall
8 reimburse for covered drugs which are dispensed under the
9 program by a provider pharmacy only pursuant to the terms of
10 the rebate agreement between the program and such
11 manufacturer, however, the program may reimburse for any
12 covered drugs pursuant to paragraphs (a) and (b) which are
13 rated 1-A by the Federal Food and Drug Administration and
14 which are determined by the board to be essential to the
15 health of persons participating in the program.
16 2. The rebate agreement between such manufacturer and
17 the program for elderly pharmaceutical insurance coverage
18 shall use for covered single source drugs and innovator
19 multiple source drugs the identical formula used to determine
20 the basic rebate for federal financial participation for
21 single source drugs and innovator multiple source drugs,
22 pursuant to s. 1927(c)(1) of the Federal Social Security Act,
23 to determine the amount of the rebate pursuant to this
24 paragraph. The rebate agreement between such manufacturer and
25 the program for elderly pharmaceutical insurance coverage
26 shall use for non-innovator multiple source drugs, the
27 identical formula used to determine the basic rebate for
28 federal financial participation for non-innovator multiple
29 source drugs, pursuant to s. 1927(c)(3) of the Federal Social
30 Security Act, to determine the amount of the rebate pursuant
31 to this subparagraph. The amount of rebate shall be calculated
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1 by multiplying the required rebate formulas by the total
2 number of units of each dosage form and strength dispensed.
3 The rebate agreement shall also provide for periodic payment
4 of the rebate, provision of information to the program,
5 audits, verification of data and confidentiality of
6 information.
7 3. The program, in providing utilization data to a
8 manufacturer as provided for under s. 1927(b) of the Federal
9 Social Security Act, shall provide such data by zip code, if
10 requested, for the top 300 most commonly used drugs by volume
11 covered under a rebate agreement.
12 4. Any funds collected pursuant to any rebate
13 agreements entered into with a manufacturer pursuant to this
14 paragraph, shall be deposited into the General Revenue Fund.
15 (12) PENALTIES FOR FRAUD AND ABUSE.--
16 (a) Any person who knowingly makes a false statement
17 or representation, or who, by deliberate concealment of any
18 material fact or by impersonation or other fraudulent device,
19 obtains or attempts to obtain or aids or abets any person to
20 obtain any benefit under this act to which he or she is not
21 entitled, commits a misdemeanor of the first degree,
22 punishable as provided in s. 775.082 and s. 775.083, Florida
23 Statutes.
24 (b) Any person who, having made application to receive
25 any benefit under this act for the use and benefit of another
26 and having received such benefit, knowingly and willfully
27 converts such benefit or any part of such benefit to a use
28 other than for the use and benefit of such other person
29 commits a misdemeanor of the first degree, punishable as
30 provided in s. 775.082 and s. 775.083, Florida Statutes.
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1 (c) Any person who, with intent to defraud, presents
2 for allowance or payment any false or fraudulent claim for
3 furnishing services or merchandise, or knowingly submits false
4 information for the purpose of obtaining greater compensation
5 than that to which such person is legally entitled for
6 furnishing services or merchandise, or knowingly submits false
7 information for the purpose of obtaining authorization for
8 furnishing services or merchandise under this act commits a
9 misdemeanor of the first degree, punishable as provided in s.
10 775.082 and s. 775.083, Florida Statutes.
11 (13) PROCEDURES FOR DETERMINATIONS RELATING TO
12 PACKAGE, OR FORM OF DOSAGE OR ADMINISTRATION, OF CERTAIN
13 DRUGS.--
14 (a) If the Secretary of Health makes an initial
15 determination that a particular package, or form of dosage or
16 administration, of a drug does not constitute a covered drug
17 for purposes of this act due to the availability of a less
18 expensive package, or form of dosage or administration, that
19 is pharmaceutically equivalent and equivalent in its
20 therapeutic effect for the general health characteristics of
21 the eligible program participant population, the department
22 shall notify the manufacturer of such drug product that the
23 department intends to exclude such package, or form of dosage
24 or administration, from the program and shall provide such
25 manufacturer with the reasons for such exclusion together with
26 the facts which the department relies upon to support its
27 initial determination. The manufacturer shall have 15 days
28 after receiving such exclusion notice to notify the department
29 of an intent to appeal the decision. If the manufacturer fails
30 to notify the department of an intent to appeal within the
31 time specified in this subsection, the Secretary of Health
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1 shall immediately thereafter determine whether the package, or
2 form of dosage or administration, shall be excluded from the
3 program. If the manufacturer notifies the department of an
4 intent to appeal, the manufacturer shall submit to the
5 department, within 45 days after receiving such exclusion
6 notice, the basis of the manufacturer's appeal. Within 15 days
7 after receiving such submission from the manufacturer, the
8 department shall provide to the manufacturer any additional
9 facts concerning the drug product that the department relies
10 upon to support its initial determination. Within 10 days
11 after receiving such facts, the manufacturer may submit
12 additional facts concerning the drug package, or form of
13 dosage or administration. Based on the facts submitted
14 pursuant to this subsection, the Secretary of Health shall
15 make a final determination as to whether or not the package,
16 or form of dosage or administration, of the drug product
17 constitutes a covered drug for the purposes of this act. A
18 determination that a drug package, or form of dosage or
19 administration, does not constitute a covered drug for
20 purposes of this act is subject to judicial review.
21 (b) Notwithstanding paragraph (a), the Department of
22 Health shall establish by rule an appropriate process for
23 allowing drug packages, or forms of dosage or administration,
24 finally determined under this subsection not to be covered
25 drugs for the purposes of this act to be dispensed to program
26 participants for whom such drug packages, or forms of dosage
27 or administration, are medically indicated as certified to by
28 a physician treating such participant. Any such drug package,
29 or form of dosage or administration, so certified as medically
30 indicated for a specific participant in accordance with such
31 rules shall be a covered drug for the purpose of this act.
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1 (14) USE OF OUT-OF-STATE PROVIDER PHARMACIES;
2 NECESSITY AND CONVENIENCE.--
3 (a) In counties having a population of 75,000 or less
4 that are in proximity to the state boundary and which are
5 determined by the executive director to be not adequately
6 served by provider pharmacies registered in this state, the
7 executive director may approve as provider pharmacies,
8 pharmacies located in Alabama and Georgia. Such approvals
9 shall be made after:
10 (a) Consideration of the convenience and necessity of
11 residents of this state in the rural areas served by such
12 pharmacies.
13 (b) Consideration of the quality of service of such
14 pharmacies and the standing of such pharmacies with the
15 governmental board or agency of the state in which such
16 pharmacy is located.
17 (c) The executive director shall give all licensed
18 pharmacies within the county notice of his intention to
19 approve such out-of-state provider pharmacies.
20 (d) The executive director has held a public hearing
21 at which he or she has determined factually that the licensed
22 pharmacies within such county are not adequately serving as
23 provider pharmacies.
24 (e) The executive director shall investigate and
25 determine whether certification shall be granted within 90
26 days after the filing of an application for certification by
27 the governing body of any municipality within a a county
28 determined by the executive director to be not adequately
29 served by provider pharmacies registered in this state
30 pursuant to paragraph (a), claiming to be lacking adequate
31 pharmaceutical service.
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1 (f) Every certification granted pursuant to this
2 subsection shall expire not more than 5 years after the date
3 of issuance.
4 Section 2. This act shall take effect October 1, 2000.
5
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7 HOUSE 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.
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