Florida Senate - 2019 COMMITTEE AMENDMENT
Bill No. CS for CS for SB 1180
Ì385052ÇÎ385052
LEGISLATIVE ACTION
Senate . House
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The Committee on Rules (Mayfield) recommended the following:
1 Senate Amendment to Amendment (635224) (with title
2 amendment)
3
4 Delete lines 16 - 166
5 and insert:
6 (5)(a) This section does not apply if a drug manufacturer
7 increases the list price of a prescription drug on the health
8 insurer’s formulary to the health insurer or the pharmacy
9 benefit manager after November 1 of the year before the health
10 insurer’s earliest required rate submission date to applicable
11 state and federal rate review authorities for the succeeding
12 calendar or policy year.
13 (b) However, at least 60 days before the effective date of
14 a formulary change as a result of circumstances described in
15 paragraph (a), the health insurer shall provide general
16 notification of the formulary changes to current and prospective
17 insureds in a readily accessible format on the insurer’s
18 website; and notify, electronically or by first-class mail, any
19 insured currently receiving coverage for a prescription drug for
20 which the formulary change modifies coverage and the insured’s
21 treating physician, including information on the specific drugs
22 involved.
23 (6) A health insurer shall maintain a record of any change
24 in its formulary during the calendar or plan year and, within 45
25 days after the end of the plan year, submit an annual report to
26 the office delineating such changes. The commission shall
27 prescribe a form by rule for such reports.
28 Section 2. Paragraph (e) of subsection (5) of section
29 627.6699, Florida Statutes, is amended to read:
30 627.6699 Employee Health Care Access Act.—
31 (5) AVAILABILITY OF COVERAGE.—
32 (e) All health benefit plans issued under this section must
33 comply with the following conditions:
34 1. For employers who have fewer than two employees, a late
35 enrollee may be excluded from coverage for no longer than 24
36 months if he or she was not covered by creditable coverage
37 continually to a date not more than 63 days before the effective
38 date of his or her new coverage.
39 2. Any requirement used by a small employer carrier in
40 determining whether to provide coverage to a small employer
41 group, including requirements for minimum participation of
42 eligible employees and minimum employer contributions, must be
43 applied uniformly among all small employer groups having the
44 same number of eligible employees applying for coverage or
45 receiving coverage from the small employer carrier, except that
46 a small employer carrier that participates in, administers, or
47 issues health benefits pursuant to s. 381.0406 which do not
48 include a preexisting condition exclusion may require as a
49 condition of offering such benefits that the employer has had no
50 health insurance coverage for its employees for a period of at
51 least 6 months. A small employer carrier may vary application of
52 minimum participation requirements and minimum employer
53 contribution requirements only by the size of the small employer
54 group.
55 3. In applying minimum participation requirements with
56 respect to a small employer, a small employer carrier shall not
57 consider as an eligible employee employees or dependents who
58 have qualifying existing coverage in an employer-based group
59 insurance plan or an ERISA qualified self-insurance plan in
60 determining whether the applicable percentage of participation
61 is met. However, a small employer carrier may count eligible
62 employees and dependents who have coverage under another health
63 plan that is sponsored by that employer.
64 4. A small employer carrier shall not increase any
65 requirement for minimum employee participation or any
66 requirement for minimum employer contribution applicable to a
67 small employer at any time after the small employer has been
68 accepted for coverage, unless the employer size has changed, in
69 which case the small employer carrier may apply the requirements
70 that are applicable to the new group size.
71 5. If a small employer carrier offers coverage to a small
72 employer, it must offer coverage to all the small employer’s
73 eligible employees and their dependents. A small employer
74 carrier may not offer coverage limited to certain persons in a
75 group or to part of a group, except with respect to late
76 enrollees.
77 6. A small employer carrier may not modify any health
78 benefit plan issued to a small employer with respect to a small
79 employer or any eligible employee or dependent through riders,
80 endorsements, or otherwise to restrict or exclude coverage for
81 certain diseases or medical conditions otherwise covered by the
82 health benefit plan.
83 7. An initial enrollment period of at least 30 days must be
84 provided. An annual 30-day open enrollment period must be
85 offered to each small employer’s eligible employees and their
86 dependents. A small employer carrier must provide special
87 enrollment periods as required by s. 627.65615.
88 8. A small employer carrier shall comply with s. 627.42393
89 for any change to a prescription drug formulary.
90 Section 3. Subsection (36) of section 641.31, Florida
91 Statutes, is amended to read:
92 641.31 Health maintenance contracts.—
93 (36) Except as provided in paragraphs (a), (b), and (c), a
94 health maintenance organization may increase the copayment for
95 any benefit, or delete, amend, or limit any of the benefits to
96 which a subscriber is entitled under the group contract only,
97 upon written notice to the contract holder at least 45 days in
98 advance of the time of coverage renewal. The health maintenance
99 organization may amend the contract with the contract holder,
100 with such amendment to be effective immediately at the time of
101 coverage renewal. The written notice to the contract holder must
102 shall specifically identify any deletions, amendments, or
103 limitations to any of the benefits provided in the group
104 contract during the current contract period which will be
105 included in the group contract upon renewal. This subsection
106 does not apply to any increases in benefits. The 45-day notice
107 requirement does shall not apply if benefits are amended,
108 deleted, or limited at the request of the contract holder.
109 (a) At least 60 days before the effective date of any
110 change to a prescription drug formulary during a contract year,
111 the health maintenance organization shall:
112 1. Provide general notification of the change in the
113 formulary to current and prospective subscribers in a readily
114 accessible format on the health maintenance organization’s
115 website; and
116 2. Notify, electronically or by first-class mail, any
117 subscriber currently receiving coverage for a prescription drug
118 for which the formulary change modifies coverage and the
119 subscriber’s treating physician, including information on the
120 specific drugs involved and a statement that the submission of a
121 notice of medical necessity by the subscriber’s treating
122 physician to the health maintenance organization at least 30
123 days before the effective date of the formulary change will
124 result in continuation of coverage at the existing level.
125 (b) The notice provided by the treating physician to the
126 insurer must include a completed one-page form in which the
127 treating physician certifies to the health maintenance
128 organization that coverage of the prescription drug for the
129 subscriber is medically necessary. The treating physician shall
130 submit the notice electronically or by first-class mail. The
131 health maintenance organization may provide the treating
132 physician with access to an electronic portal through which the
133 treating physician may electronically file the notice. The
134 commission shall prescribe a form by rule for the notice.
135 (c) If the treating physician certifies to the health
136 maintenance organization, in accordance with paragraph (b), that
137 the prescription drug is medically necessary for the subscriber,
138 the health maintenance organization:
139 1. Must authorize coverage for the prescribed drug based
140 solely on the treating physician’s certification that coverage
141 is medically necessary; and
142 2. May not modify the coverage related to the covered drug
143 by:
144 a. Increasing the out-of-pocket costs for the covered drug;
145 b. Moving the covered drug to a more restrictive tier; or
146 c. Denying a subscriber coverage of the drug for which the
147 subscriber has been previously approved for coverage by the
148 health maintenance organization.
149 (d) Paragraphs (a), (b), and (c) do not:
150 1. Prohibit the addition of prescription drugs to the list
151 of drugs covered under the contract during the contract year.
152 2. Apply to a grandfathered health plan as defined in s.
153 627.402 or to benefits specified in s. 627.6513(1)-(14).
154 3. Alter or amend s. 465.025, which provides conditions
155 under which a pharmacist may substitute a generically equivalent
156 drug product for a brand name drug product.
157 4. Alter or amend s. 465.0252, which provides conditions
158 under which a pharmacist may dispense a substitute biological
159 product for the prescribed biological product.
160 5. Apply to a Medicaid managed care plan under part IV of
161 chapter 409.
162 (e)1. Paragraphs (a), (b), and (c) do not apply if a drug
163 manufacturer increases the list price of a prescription drug on
164 the health maintenance organization’s formulary to the health
165 maintenance organization or the pharmacy benefit manager after
166 November 1 of the year before the health maintenance
167 organization’s earliest required rate submission date to
168 applicable state and federal rate review authorities for the
169 succeeding calendar or policy year.
170 2. However, at least 60 days before the effective date of a
171 formulary change as a result of circumstances described in
172 subparagraph 1., the health maintenance organization shall
173 provide general notification of the formulary changes to current
174 and prospective subscribers in a readily accessible format on
175 the health maintenance organization’s website; and notify,
176 electronically or by first-class mail, any subscriber currently
177 receiving coverage for a prescription drug for which the
178 formulary change modifies coverage and the subscriber’s treating
179 physician, including information on the specific drugs involved.
180 (f) A health maintenance organization shall maintain a
181 record of any change in its formulary during the calendar or
182 plan year and, within 45 days after the end of the plan year,
183 submit an annual report to the office delineating such changes.
184 The commission shall prescribe a form by rule for such reports.
185
186 ================= T I T L E A M E N D M E N T ================
187 And the title is amended as follows:
188 Delete lines 172 - 194
189 and insert:
190 applicability; providing an exception for certain
191 increases in prescription drug prices by the drug
192 manufacturer; specifying notification requirements for
193 insurers under such circumstances; requiring insurers
194 to maintain a record of formulary changes and submit
195 an annual report to the Office of Insurance Regulation
196 delineating such changes within a certain timeframe;
197 requiring the Financial Services Commission to adopt a
198 certain form by rule; amending s. 627.6699, F.S.;
199 requiring small employer carriers to comply with
200 certain requirements for any change to a prescription
201 drug formulary under the health benefit plan; amending
202 s. 641.31, F.S.; requiring health maintenance
203 organizations to provide certain notices to current
204 and prospective subscribers within a certain timeframe
205 before the effective date of any change to a
206 prescription drug formulary during a contract year;
207 specifying requirements for a notice of medical
208 necessity that a subscriber’s treating physician may
209 submit to the health maintenance organization within a
210 certain timeframe; specifying means by which the
211 notice is to be submitted; requiring the commission to
212 adopt a certain rule; specifying a requirement and
213 prohibited acts relating to coverage changes by a
214 health maintenance organization if the treating
215 physician provides certain certification; providing
216 construction and applicability; providing an exception
217 for certain increases in prescription drug prices by
218 the drug manufacturer; specifying notification
219 requirements for health maintenance organizations
220 under such circumstances; requiring health maintenance
221 organizations to maintain a record of formulary
222 changes and submit an annual report to the office
223 delineating such changes within a certain timeframe;
224 requiring the commission to adopt a certain form by
225 rule; providing a