Florida Senate - 2019 COMMITTEE AMENDMENT
Bill No. CS for SB 1180
Ì260342vÎ260342
LEGISLATIVE ACTION
Senate . House
Comm: RCS .
04/08/2019 .
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The Committee on Health Policy (Mayfield) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Section 627.42393, Florida Statutes, is created
6 to read:
7 627.42393 Health insurance policies; changes to
8 prescription drug formularies; requirements.—
9 (1) At least 60 days before the effective date of any
10 change to a prescription drug formulary during a policy year, an
11 insurer issuing individual or group health insurance policies in
12 this state shall:
13 (a) Provide general notification of the change in the
14 formulary to current and prospective insureds in a readily
15 accessible format on the insurer’s website; and
16 (b) Notify, electronically or by first-class mail, any
17 insured currently receiving coverage for a prescription drug for
18 which the formulary change modifies coverage and the insured’s
19 treating physician, including information on the specific drugs
20 involved and a statement that the submission of a notice of
21 medical necessity by the insured’s treating physician to the
22 insurer at least 30 days before the effective date of the
23 formulary change will result in continuation of coverage at the
24 existing level.
25 (2) The notice provided by the treating physician to the
26 insurer must include a completed one-page form in which the
27 treating physician certifies to the insurer that coverage of the
28 prescription drug for the insured is medically necessary. The
29 treating physician shall submit the notice electronically or by
30 first-class mail. The insurer may provide the treating physician
31 with access to an electronic portal through which the treating
32 physician may electronically file the notice. The commission
33 shall prescribe a form by rule for the notice.
34 (3) If the treating physician certifies to the insurer, in
35 accordance with subsection (2), that the prescription drug is
36 medically necessary for the insured, the insurer:
37 (a) Must authorize coverage for the prescribed drug based
38 solely on the treating physician’s certification that coverage
39 is medically necessary; and
40 (b) May not modify the coverage related to the covered drug
41 by:
42 1. Increasing the out-of-pocket costs for the covered drug;
43 2. Moving the covered drug to a more restrictive tier; or
44 3. Denying an insured coverage of the drug for which the
45 insured has been previously approved for coverage by the
46 insurer.
47 (4) This section does not:
48 (a) Prohibit the addition of prescription drugs to the list
49 of drugs covered under the policy during the policy year.
50 (b) Apply to a grandfathered health plan as defined in s.
51 627.402 or to benefits specified in s. 627.6513(1)-(14).
52 (c) Alter or amend s. 465.025, which provides conditions
53 under which a pharmacist may substitute a generically equivalent
54 drug product for a brand name drug product.
55 (d) Alter or amend s. 465.0252, which provides conditions
56 under which a pharmacist may dispense a substitute biological
57 product for the prescribed biological product.
58 (e) Apply to a Medicaid managed care plan under part IV of
59 chapter 409.
60 Section 2. Paragraph (e) of subsection (5) of section
61 627.6699, Florida Statutes, is amended to read:
62 627.6699 Employee Health Care Access Act.—
63 (5) AVAILABILITY OF COVERAGE.—
64 (e) All health benefit plans issued under this section must
65 comply with the following conditions:
66 1. For employers who have fewer than two employees, a late
67 enrollee may be excluded from coverage for no longer than 24
68 months if he or she was not covered by creditable coverage
69 continually to a date not more than 63 days before the effective
70 date of his or her new coverage.
71 2. Any requirement used by a small employer carrier in
72 determining whether to provide coverage to a small employer
73 group, including requirements for minimum participation of
74 eligible employees and minimum employer contributions, must be
75 applied uniformly among all small employer groups having the
76 same number of eligible employees applying for coverage or
77 receiving coverage from the small employer carrier, except that
78 a small employer carrier that participates in, administers, or
79 issues health benefits pursuant to s. 381.0406 which do not
80 include a preexisting condition exclusion may require as a
81 condition of offering such benefits that the employer has had no
82 health insurance coverage for its employees for a period of at
83 least 6 months. A small employer carrier may vary application of
84 minimum participation requirements and minimum employer
85 contribution requirements only by the size of the small employer
86 group.
87 3. In applying minimum participation requirements with
88 respect to a small employer, a small employer carrier shall not
89 consider as an eligible employee employees or dependents who
90 have qualifying existing coverage in an employer-based group
91 insurance plan or an ERISA qualified self-insurance plan in
92 determining whether the applicable percentage of participation
93 is met. However, a small employer carrier may count eligible
94 employees and dependents who have coverage under another health
95 plan that is sponsored by that employer.
96 4. A small employer carrier shall not increase any
97 requirement for minimum employee participation or any
98 requirement for minimum employer contribution applicable to a
99 small employer at any time after the small employer has been
100 accepted for coverage, unless the employer size has changed, in
101 which case the small employer carrier may apply the requirements
102 that are applicable to the new group size.
103 5. If a small employer carrier offers coverage to a small
104 employer, it must offer coverage to all the small employer’s
105 eligible employees and their dependents. A small employer
106 carrier may not offer coverage limited to certain persons in a
107 group or to part of a group, except with respect to late
108 enrollees.
109 6. A small employer carrier may not modify any health
110 benefit plan issued to a small employer with respect to a small
111 employer or any eligible employee or dependent through riders,
112 endorsements, or otherwise to restrict or exclude coverage for
113 certain diseases or medical conditions otherwise covered by the
114 health benefit plan.
115 7. An initial enrollment period of at least 30 days must be
116 provided. An annual 30-day open enrollment period must be
117 offered to each small employer’s eligible employees and their
118 dependents. A small employer carrier must provide special
119 enrollment periods as required by s. 627.65615.
120 8. A small employer carrier shall comply with s. 627.42393
121 for any change to a prescription drug formulary.
122 Section 3. Subsection (36) of section 641.31, Florida
123 Statutes, is amended to read:
124 641.31 Health maintenance contracts.—
125 (36) Except as provided in paragraphs (a), (b), and (c), a
126 health maintenance organization may increase the copayment for
127 any benefit, or delete, amend, or limit any of the benefits to
128 which a subscriber is entitled under the group contract only,
129 upon written notice to the contract holder at least 45 days in
130 advance of the time of coverage renewal. The health maintenance
131 organization may amend the contract with the contract holder,
132 with such amendment to be effective immediately at the time of
133 coverage renewal. The written notice to the contract holder must
134 shall specifically identify any deletions, amendments, or
135 limitations to any of the benefits provided in the group
136 contract during the current contract period which will be
137 included in the group contract upon renewal. This subsection
138 does not apply to any increases in benefits. The 45-day notice
139 requirement does shall not apply if benefits are amended,
140 deleted, or limited at the request of the contract holder.
141 (a) At least 60 days before the effective date of any
142 change to a prescription drug formulary during a contract year,
143 the health maintenance organization shall:
144 1. Provide general notification of the change in the
145 formulary to current and prospective subscribers in a readily
146 accessible format on the health maintenance organization’s
147 website; and
148 2. Notify, electronically or by first-class mail, any
149 subscriber currently receiving coverage for a prescription drug
150 for which the formulary change modifies coverage and the
151 subscriber’s treating physician, including information on the
152 specific drugs involved and a statement that the submission of a
153 notice of medical necessity by the subscriber’s treating
154 physician to the health maintenance organization at least 30
155 days before the effective date of the formulary change will
156 result in continuation of coverage at the existing level.
157 (b) The notice provided by the treating physician to the
158 insurer must include a completed one-page form in which the
159 treating physician certifies to the health maintenance
160 organization that coverage of the prescription drug for the
161 subscriber is medically necessary. The treating physician shall
162 submit the notice electronically or by first-class mail. The
163 health maintenance organization may provide the treating
164 physician with access to an electronic portal through which the
165 treating physician may electronically file the notice. The
166 commission shall prescribe a form by rule for the notice.
167 (c) If the treating physician certifies to the health
168 maintenance organization, in accordance with paragraph (b), that
169 the prescription drug is medically necessary for the subscriber,
170 the health maintenance organization:
171 1. Must authorize coverage for the prescribed drug based
172 solely on the treating physician’s certification that coverage
173 is medically necessary; and
174 2. May not modify the coverage related to the covered drug
175 by:
176 a. Increasing the out-of-pocket costs for the covered drug;
177 b. Moving the covered drug to a more restrictive tier; or
178 c. Denying a subscriber coverage of the drug for which the
179 subscriber has been previously approved for coverage by the
180 health maintenance organization.
181 (d) Paragraphs (a), (b), and (c) do not:
182 1. Prohibit the addition of prescription drugs to the list
183 of drugs covered under the contract during the contract year.
184 2. Apply to a grandfathered health plan as defined in s.
185 627.402 or to benefits specified in s. 627.6513(1)-(14).
186 3. Alter or amend s. 465.025, which provides conditions
187 under which a pharmacist may substitute a generically equivalent
188 drug product for a brand name drug product.
189 4. Alter or amend s. 465.0252, which provides conditions
190 under which a pharmacist may dispense a substitute biological
191 product for the prescribed biological product.
192 5. Apply to a Medicaid managed care plan under part IV of
193 chapter 409.
194 Section 4. The Legislature finds that this act fulfills an
195 important state interest.
196 Section 5. This act shall take effect January 1, 2020.
197
198 ================= T I T L E A M E N D M E N T ================
199 And the title is amended as follows:
200 Delete everything before the enacting clause
201 and insert:
202 A bill to be entitled
203 An act relating to prescription drug formulary
204 consumer protection; creating s. 627.42393, F.S.;
205 requiring insurers issuing individual or group health
206 insurance policies to provide certain notices to
207 current and prospective insureds within a certain
208 timeframe before the effective date of any change to a
209 prescription drug formulary during a policy year;
210 specifying requirements for a notice of medical
211 necessity that an insured’s treating physician may
212 submit to the insurer within a certain timeframe;
213 specifying means by which the notice is to be
214 submitted; requiring the Financial Services Commission
215 to adopt a certain rule; specifying a requirement and
216 prohibited acts relating to coverage changes by an
217 insurer if the treating physician provides certain
218 certification; providing construction and
219 applicability; amending s. 627.6699, F.S.; requiring
220 small employer carriers to comply with certain
221 requirements for any change to a prescription drug
222 formulary under the health benefit plan; amending s.
223 641.31, F.S.; requiring health maintenance
224 organizations to provide certain notices to current
225 and prospective subscribers within a certain timeframe
226 before the effective date of any change to a
227 prescription drug formulary during a contract year;
228 specifying requirements for a notice of medical
229 necessity that a subscriber’s treating physician may
230 submit to the health maintenance organization within a
231 certain timeframe; specifying means by which the
232 notice is to be submitted; requiring the commission to
233 adopt a certain rule; specifying a requirement and
234 prohibited acts relating to coverage changes by a
235 health maintenance organization if the treating
236 physician provides certain certification; providing
237 construction and applicability; providing a
238 declaration of important state interest; providing an
239 effective date.