Florida Senate - 2026 SB 1166
By Senator Rodriguez
40-00510-26 20261166__
1 A bill to be entitled
2 An act relating to insurer disclosures on prescription
3 drug coverage; creating s. 627.42394, F.S.; requiring
4 individual and group health insurers to provide notice
5 of prescription drug formulary changes within a
6 certain timeframe to current and prospective insureds
7 and the insureds’ treating physicians; specifying
8 requirements for the content of such notice and the
9 manner in which it must be provided; specifying
10 requirements for a notice of medical necessity
11 submitted by the treating physician; authorizing
12 insurers to provide certain means for submitting the
13 notice of medical necessity; requiring the Financial
14 Services Commission to adopt a certain form by rule by
15 a specified date; specifying a coverage requirement
16 and restrictions on coverage modification by insurers
17 receiving a notice of medical necessity; providing
18 construction and applicability; requiring insurers to
19 maintain a record of formulary changes; requiring
20 insurers to annually submit a specified report to the
21 Office of Insurance Regulation by a specified date;
22 requiring the office to annually compile certain data
23 and prepare a report, make the report publicly
24 accessible on its website, and submit the report to
25 the Governor and the Legislature by a specified date;
26 creating s. 627.6383, F.S.; defining the term “cost
27 sharing requirement”; requiring specified individual
28 health insurers and their pharmacy benefit managers to
29 apply payments for prescription drugs by or on behalf
30 of insureds toward the insureds’ total contributions
31 to cost-sharing requirements under certain
32 circumstances; providing construction; requiring
33 specified individual health insurers to maintain
34 records of certain third-party payments for
35 prescription drugs; providing reporting requirements
36 relating to third-party payments for prescription
37 drugs; providing requirements for the reports;
38 providing applicability; amending s. 627.6385, F.S.;
39 providing disclosure requirements relating to a
40 policyholder’s total cost-sharing requirement for
41 prescription drugs; providing applicability; amending
42 s. 627.64741, F.S.; requiring that specified contracts
43 require pharmacy benefit managers to apply payments by
44 or on behalf of insureds toward the insureds’ total
45 contributions to cost-sharing requirements; providing
46 applicability; providing disclosure requirements
47 relating to a policyholder’s total cost-sharing
48 requirement for prescription drugs; creating s.
49 627.65715, F.S.; defining the term “cost-sharing
50 requirement”; requiring specified group health
51 insurers and their pharmacy benefit managers to apply
52 payments for prescription drugs by or on behalf of
53 insureds toward the insureds’ total contributions to
54 cost-sharing requirements under certain circumstances;
55 providing construction; providing disclosure
56 requirements relating to an insured person’s total
57 cost-sharing requirement for prescription drugs;
58 requiring specified group health insurers to maintain
59 records of certain third-party payments for
60 prescription drugs; providing reporting requirements;
61 providing requirements for the reports; providing
62 applicability; amending s. 627.6572, F.S.; requiring
63 that specified contracts require pharmacy benefit
64 managers to apply payments by or on behalf of insureds
65 toward the insureds’ total contributions to cost
66 sharing requirements; providing applicability;
67 providing disclosure requirements; amending s.
68 627.6699, F.S.; requiring small employer carriers to
69 comply with certain requirements for prescription drug
70 formulary changes; amending s. 641.31, F.S.; providing
71 an exception to requirements relating to changes in a
72 health maintenance organization’s group contract;
73 requiring health maintenance organizations to provide
74 notice of prescription drug formulary changes within a
75 certain timeframe to current and prospective
76 subscribers and the subscribers’ treating physicians;
77 specifying requirements for the content of such notice
78 and the manner in which it must be provided;
79 specifying requirements for a notice of medical
80 necessity submitted by the treating physician;
81 authorizing health maintenance organizations to
82 provide certain means for submitting the notice of
83 medical necessity; requiring the commission to adopt a
84 certain form by rule by a specified date; specifying a
85 coverage requirement and restrictions on coverage
86 modification by health maintenance organizations
87 receiving a notice of medical necessity; providing
88 construction and applicability; requiring health
89 maintenance organizations to maintain a record of
90 formulary changes; requiring health maintenance
91 organizations to annually submit a specified report to
92 the office by a specified date; requiring the office
93 to annually compile certain data and prepare a report,
94 make the report publicly accessible on its website,
95 and submit the report to the Governor and the
96 Legislature by a specified date; defining the term
97 “cost-sharing requirement”; requiring specified health
98 maintenance organizations and their pharmacy benefit
99 managers to apply payments for prescription drugs by
100 or on behalf of subscribers toward the subscribers’
101 total contributions to cost-sharing requirements under
102 certain circumstances; providing construction;
103 providing disclosure requirements relating to the
104 subscriber’s total contributions to cost-sharing
105 requirements; requiring specified health maintenance
106 organizations to maintain records of certain third
107 party payments for prescription drugs; providing
108 reporting requirements; providing requirements for the
109 reports; providing applicability; amending s. 641.314,
110 F.S.; requiring that specified contracts require
111 pharmacy benefit managers to apply payments by or on
112 behalf of subscribers toward the subscribers’ total
113 contributions to cost-sharing requirements; providing
114 applicability; providing disclosure requirements
115 relating to a subscriber’s total cost-sharing
116 requirement for prescription drugs; amending s.
117 409.967, F.S.; conforming a cross-reference; amending
118 s. 641.185, F.S.; conforming a provision to changes
119 made by the act; providing applicability; providing a
120 declaration of important state interest; providing an
121 effective date.
122
123 Be It Enacted by the Legislature of the State of Florida:
124
125 Section 1. Section 627.42394, Florida Statutes, is created
126 to read:
127 627.42394 Health insurance policies; changes to
128 prescription drug formularies; requirements.—
129 (1) At least 60 days before the effective date of any
130 change to a prescription drug formulary during a policy year, an
131 insurer issuing individual or group health insurance policies in
132 this state shall notify:
133 (a) Current and prospective insureds of the change in the
134 formulary, in a readily accessible format on the insurer’s
135 website; and
136 (b) Any insured currently receiving coverage for a
137 prescription drug for whom the formulary change modifies
138 coverage and the insured’s treating physician. Such notification
139 must be sent electronically and by first-class mail and must
140 include information on the specific drugs involved and a
141 statement that the submission of a notice of medical necessity
142 by the insured’s treating physician to the insurer at least 30
143 days before the effective date of the formulary change will
144 result in continuation of coverage at the existing level.
145 (2) The notice of medical necessity provided by the
146 treating physician to the insurer must include a completed one
147 page form in which the treating physician certifies to the
148 insurer that the prescription drug for the insured is medically
149 necessary as defined in s. 627.732(2). The treating physician
150 shall submit the notice electronically or by first-class mail.
151 The insurer may provide the treating physician with access to an
152 electronic portal through which the treating physician may
153 electronically submit the notice. By January 1, 2027, the
154 commission shall adopt by rule a form for the notice.
155 (3) If the treating physician certifies to the insurer in
156 accordance with subsection (2) that the prescription drug is
157 medically necessary for the insured, the insurer:
158 (a) Must authorize coverage for the prescribed drug until
159 the end of the policy year, based solely on the treating
160 physician’s certification that the drug is medically necessary;
161 and
162 (b) May not modify the coverage related to the covered drug
163 during the policy year by:
164 1. Increasing the out-of-pocket costs for the covered drug;
165 2. Moving the covered drug to a more restrictive tier;
166 3. Denying an insured coverage of the drug for which the
167 insured has been previously approved for coverage by the
168 insurer; or
169 4. Limiting or reducing coverage of the drug in any other
170 way, including subjecting it to a new prior authorization or
171 step-therapy requirement.
172 (4) Subsections (1), (2), and (3) do not:
173 (a) Prohibit the addition of prescription drugs to the list
174 of drugs covered under the policy during the policy year.
175 (b) Apply to a grandfathered health plan as defined in s.
176 627.402 or to benefits specified in s. 627.6513.
177 (c) Alter or amend s. 465.025, which provides conditions
178 under which a pharmacist may substitute a generically equivalent
179 drug product for a brand name drug product.
180 (d) Alter or amend s. 465.0252, which provides conditions
181 under which a pharmacist may dispense a substitute biological
182 product for the prescribed biological product.
183 (e) Apply to a Medicaid managed care plan under part IV of
184 chapter 409.
185 (5) A health insurer shall maintain a record of any change
186 in its formulary during a calendar year. By March 1 of each
187 year, a health insurer shall submit to the office a report
188 delineating such changes made in the previous calendar year. The
189 annual report must include all of the following, at a minimum:
190 (a) A list of all drugs removed from the formulary, along
191 with the date of the removal and the reasons for the removal.
192 (b) A list of all drugs moved to a tier resulting in
193 additional out-of-pocket costs to insureds.
194 (c) The number of insureds impacted by a change in the
195 formulary.
196 (d) The number of insureds notified by the insurer of a
197 change in the formulary.
198 (e) The increased cost, by dollar amount, incurred by
199 insureds because of such change in the formulary.
200 (6) By May 1 of each year, the office shall:
201 (a) Compile the data in the annual reports submitted by
202 health insurers under subsection (5) and prepare a report
203 summarizing such data.
204 (b) Make the report publicly accessible on its website.
205 (c) Submit the report to the Governor, the President of the
206 Senate, and the Speaker of the House of Representatives.
207 Section 2. Section 627.6383, Florida Statutes, is created
208 to read:
209 627.6383 Cost-sharing requirements.—
210 (1) As used in this section, the term “cost-sharing
211 requirement” means a dollar limit, a deductible, a copayment,
212 coinsurance, or any other out-of-pocket expense imposed on an
213 insured, including, but not limited to, the annual limitation on
214 cost sharing subject to 42 U.S.C. s. 18022.
215 (2)(a) Each health insurer issuing, delivering, or renewing
216 a policy in this state which provides prescription drug
217 coverage, or each pharmacy benefit manager on behalf of such
218 health insurer, shall apply any amount paid for a prescription
219 drug by an insured or by another person on behalf of the insured
220 toward the insured’s total contribution to any cost-sharing
221 requirement, if the prescription drug:
222 1. Does not have a generic equivalent; or
223 2. Has a generic equivalent and the insured has obtained
224 authorization for the prescription drug through any of the
225 following:
226 a. Prior authorization from the health insurer or pharmacy
227 benefit manager.
228 b. A step-therapy protocol.
229 c. The exception or appeal process of the health insurer or
230 pharmacy benefit manager.
231 (b) The amount paid by or on behalf of the insured which is
232 applied toward the insured’s total contribution to any cost
233 sharing requirement under paragraph (a) includes, but is not
234 limited to, any payment with or any discount through financial
235 assistance, a manufacturer copay card, a product voucher, or any
236 other reduction in out-of-pocket expenses made by or on behalf
237 of the insured for a prescription drug.
238 (c)1. Each health insurer issuing, delivering, or renewing
239 a policy in this state which provides prescription drug
240 coverage, regardless of whether the prescription drug benefits
241 are administered or managed by the insurer or by a pharmacy
242 benefit manager on behalf of the insurer, shall maintain a
243 record of any third-party payments made or remitted on behalf of
244 an insured for prescription drugs, which payments are not
245 applied to the insured’s out-of-pocket obligations, including,
246 but not limited to, deductibles, copayments, or coinsurance.
247 2. By March 1 of each year, each health insurer issuing,
248 delivering, or renewing a policy in this state which provides
249 prescription drug coverage, regardless of whether the
250 prescription drug benefits are administered or managed by the
251 insurer or by a pharmacy benefit manager on behalf of the
252 insurer, shall submit to the office a report delineating third
253 party payments, as described in subparagraph 1., which were
254 received in the previous calendar year. The annual report must
255 include, at a minimum:
256 a. A list of all payments received by the health insurer,
257 as described in subparagraph 1., made or remitted by a third
258 party, which must include all of the following:
259 (I) The date each payment was made.
260 (II) The prescription drug for which the payment was made.
261 (III) The reason that the payment was not applied to the
262 insured’s out-of-pocket obligations.
263 b. The total amount of payments received by the health
264 insurer which were not applied to an insured’s out-of-pocket
265 maximum.
266 c. The total number of insureds for whom a payment was made
267 which was not applied to an out-of-pocket maximum.
268 d. Whether such payments were returned to the third party
269 that submitted the payment.
270 e. The total amount of payments which were not returned to
271 the third party that submitted the payment.
272 (3) This section applies to any health insurance policy
273 issued, delivered, or renewed in this state on or after January
274 1, 2027.
275 Section 3. Present subsections (2) and (3) of section
276 627.6385, Florida Statutes, are redesignated as subsections (3)
277 and (4), respectively, a new subsection (2) is added to that
278 section, and present subsection (2) of that section is amended,
279 to read:
280 627.6385 Disclosures to policyholders; calculations of cost
281 sharing.—
282 (2) Each health insurer issuing, delivering, or renewing a
283 policy in this state which provides prescription drug coverage,
284 regardless of whether the prescription drug benefits are
285 administered or managed by the health insurer or by a pharmacy
286 benefit manager on behalf of the health insurer, shall disclose
287 on its website that any amount paid by a policyholder or by
288 another person on behalf of the policyholder must be applied
289 toward the policyholder’s total contribution to any cost-sharing
290 requirement pursuant to s. 627.6383. This subsection applies to
291 any policy issued, delivered, or renewed in this state on or
292 after January 1, 2027.
293 (3)(2) Each health insurer shall include in every policy
294 delivered or issued for delivery to any person in this the state
295 or in materials provided as required by s. 627.64725 a notice
296 that the information required by this section is available
297 electronically and the website address of the website where the
298 information can be accessed. In addition, each health insurer
299 issuing, delivering, or renewing a policy in this state which
300 provides prescription drug coverage, regardless of whether the
301 prescription drug benefits are administered or managed by the
302 health insurer or by a pharmacy benefit manager on behalf of the
303 health insurer, shall disclose in every policy that is issued,
304 delivered, or renewed to any person in this state on or after
305 January 1, 2027, that any amount paid by a policyholder or by
306 another person on behalf of the policyholder must be applied
307 toward the policyholder’s total contribution to any cost-sharing
308 requirement pursuant to s. 627.6383.
309 Section 4. Paragraph (c) is added to subsection (2) of
310 section 627.64741, Florida Statutes, to read:
311 627.64741 Pharmacy benefit manager contracts.—
312 (2) In addition to the requirements of part VII of chapter
313 626, a contract between a health insurer and a pharmacy benefit
314 manager must require that the pharmacy benefit manager:
315 (c)1. Apply any amount paid by an insured or by another
316 person on behalf of the insured toward the insured’s total
317 contribution to any cost-sharing requirement pursuant to s.
318 627.6383. This subparagraph applies to any insured whose
319 insurance policy is issued, delivered, or renewed in this state
320 on or after January 1, 2027.
321 2. Disclose to every insured whose insurance policy is
322 issued, delivered, or renewed in this state on or after January
323 1, 2027, that the pharmacy benefit manager is required to apply
324 any amount paid by the insured or by another person on behalf of
325 the insured toward the insured’s total contribution to any cost
326 sharing requirement pursuant to s. 627.6383.
327 Section 5. Section 627.65715, Florida Statutes, is created
328 to read:
329 627.65715 Cost-sharing requirements.—
330 (1) As used in this section, the term “cost-sharing
331 requirement” means a dollar limit, a deductible, a copayment,
332 coinsurance, or any other out-of-pocket expense imposed on an
333 insured, including, but not limited to, the annual limitation on
334 cost sharing subject to 42 U.S.C. s. 18022.
335 (2)(a) Each insurer issuing, delivering, or renewing a
336 policy in this state which provides prescription drug coverage,
337 or each pharmacy benefit manager on behalf of such insurer,
338 shall apply any amount paid for a prescription drug by an
339 insured or by another person on behalf of the insured toward the
340 insured’s total contribution to any cost-sharing requirement, if
341 the prescription drug:
342 1. Does not have a generic equivalent; or
343 2. Has a generic equivalent and the insured has obtained
344 authorization for the prescription drug through any of the
345 following:
346 a. Prior authorization from the insurer or pharmacy benefit
347 manager.
348 b. A step-therapy protocol.
349 c. The exception or appeal process of the insurer or
350 pharmacy benefit manager.
351 (b) The amount paid by or on behalf of the insured which is
352 applied toward the insured’s total contribution to any cost
353 sharing requirement under paragraph (a) includes, but is not
354 limited to, any payment with or any discount through financial
355 assistance, a manufacturer copay card, a product voucher, or any
356 other reduction in out-of-pocket expenses made by or on behalf
357 of the insured for a prescription drug.
358 (3)(a) Each insurer issuing, delivering, or renewing a
359 policy in this state which provides prescription drug coverage,
360 regardless of whether the prescription drug benefits are
361 administered or managed by the insurer or by a pharmacy benefit
362 manager on behalf of the insurer, shall disclose on its website
363 and in every policy issued, delivered, or renewed in this state
364 on or after January 1, 2027, that any amount paid by an insured
365 or by another person on behalf of the insured must be applied
366 toward the insured’s total contribution to any cost-sharing
367 requirement.
368 (b)1. Each insurer issuing, delivering, or renewing a
369 policy in this state which provides prescription drug coverage,
370 regardless of whether the prescription drug benefits are
371 administered or managed by the insurer or by a pharmacy benefit
372 manager on behalf of the insurer, shall maintain a record of any
373 third-party payments made or remitted on behalf of an insured
374 for prescription drugs, which payments are not applied to the
375 insured’s out-of-pocket obligations, including, but not limited
376 to, deductibles, copayments, or coinsurance.
377 2. By March 1 of each year, each health insurer issuing,
378 delivering, or renewing a policy in this state which provides
379 prescription drug coverage, regardless of whether the
380 prescription drug benefits are administered or managed by the
381 insurer or by a pharmacy benefit manager on behalf of the
382 insurer, shall submit to the office a report delineating third
383 party payments, as described in subparagraph 1., which were
384 received in the previous calendar year. The annual report must
385 include, at a minimum:
386 a. A list of all payments received by the health insurer,
387 as described in subparagraph 1., made or remitted by a third
388 party, which must include:
389 (I) The date each payment was made.
390 (II) The prescription drug for which the payment was made.
391 (III) The reason that the payment was not applied to the
392 insured’s out-of-pocket obligations.
393 b. The total amount of payments received by the health
394 insurer which were not applied to an insured’s out-of-pocket
395 maximum.
396 c. The total number of insureds for whom a payment was made
397 which was not applied to an out-of-pocket maximum.
398 d. Whether such payments were returned to the third party
399 that submitted the payment.
400 e. The total amount of payments which were not returned to
401 the third party that submitted the payment.
402 (4) This section applies to any group health insurance
403 policy issued, delivered, or renewed in this state on or after
404 January 1, 2027.
405 Section 6. Paragraph (c) is added to subsection (2) of
406 section 627.6572, Florida Statutes, to read:
407 627.6572 Pharmacy benefit manager contracts.—
408 (2) In addition to the requirements of part VII of chapter
409 626, a contract between a health insurer and a pharmacy benefit
410 manager must require that the pharmacy benefit manager:
411 (c)1. Apply any amount paid by an insured or by another
412 person on behalf of the insured toward the insured’s total
413 contribution to any cost-sharing requirement pursuant to s.
414 627.65715. This subparagraph applies to any insured whose
415 insurance policy is issued, delivered, or renewed in this state
416 on or after January 1, 2027.
417 2. Disclose to every insured whose insurance policy is
418 issued, delivered, or renewed in this state on or after January
419 1, 2027, that the pharmacy benefit manager is required to apply
420 any amount paid by the insured or by another person on behalf of
421 the insured toward the insured’s total contribution to any cost
422 sharing requirement pursuant to s. 627.65715.
423 Section 7. Paragraph (e) of subsection (5) of section
424 627.6699, Florida Statutes, is amended to read:
425 627.6699 Employee Health Care Access Act.—
426 (5) AVAILABILITY OF COVERAGE.—
427 (e) All health benefit plans issued under this section must
428 comply with the following conditions:
429 1. For employers who have fewer than two employees, a late
430 enrollee may be excluded from coverage for no longer than 24
431 months if he or she was not covered by creditable coverage
432 continually to a date not more than 63 days before the effective
433 date of his or her new coverage.
434 2. Any requirement used by a small employer carrier in
435 determining whether to provide coverage to a small employer
436 group, including requirements for minimum participation of
437 eligible employees and minimum employer contributions, must be
438 applied uniformly among all small employer groups having the
439 same number of eligible employees applying for coverage or
440 receiving coverage from the small employer carrier, except that
441 a small employer carrier that participates in, administers, or
442 issues health benefits pursuant to s. 381.0406 which do not
443 include a preexisting condition exclusion may require as a
444 condition of offering such benefits that the employer has had no
445 health insurance coverage for its employees for a period of at
446 least 6 months. A small employer carrier may vary application of
447 minimum participation requirements and minimum employer
448 contribution requirements only by the size of the small employer
449 group.
450 3. In applying minimum participation requirements with
451 respect to a small employer, a small employer carrier may shall
452 not consider as an eligible employee employees or dependents who
453 have qualifying existing coverage in an employer-based group
454 insurance plan or an ERISA qualified self-insurance plan in
455 determining whether the applicable percentage of participation
456 is met. However, a small employer carrier may count eligible
457 employees and dependents who have coverage under another health
458 plan that is sponsored by that employer.
459 4. A small employer carrier may shall not increase any
460 requirement for minimum employee participation or any
461 requirement for minimum employer contribution applicable to a
462 small employer at any time after the small employer has been
463 accepted for coverage, unless the employer size has changed, in
464 which case the small employer carrier may apply the requirements
465 that are applicable to the new group size.
466 5. If a small employer carrier offers coverage to a small
467 employer, it must offer coverage to all the small employer’s
468 eligible employees and their dependents. A small employer
469 carrier may not offer coverage limited to certain persons in a
470 group or to part of a group, except with respect to late
471 enrollees.
472 6. A small employer carrier may not modify any health
473 benefit plan issued to a small employer with respect to a small
474 employer or any eligible employee or dependent through riders,
475 endorsements, or otherwise to restrict or exclude coverage for
476 certain diseases or medical conditions otherwise covered by the
477 health benefit plan.
478 7. An initial enrollment period of at least 30 days must be
479 provided. An annual 30-day open enrollment period must be
480 offered to each small employer’s eligible employees and their
481 dependents. A small employer carrier must provide special
482 enrollment periods as required by s. 627.65615.
483 8. A small employer carrier shall comply with s. 627.65715
484 for any change to a prescription drug formulary.
485 Section 8. Subsection (36) of section 641.31, Florida
486 Statutes, is amended, and subsection (48) is added to that
487 section, to read:
488 641.31 Health maintenance contracts.—
489 (36) Except as provided in paragraphs (a), (b), and (c), a
490 health maintenance organization may increase the copayment for
491 any benefit, or delete, amend, or limit any of the benefits to
492 which a subscriber is entitled under the group contract only,
493 upon written notice to the contract holder at least 45 days in
494 advance of the time of coverage renewal. The health maintenance
495 organization may amend the contract with the contract holder,
496 with such amendment to be effective immediately at the time of
497 coverage renewal. The written notice to the contract holder must
498 shall specifically identify any deletions, amendments, or
499 limitations to any of the benefits provided in the group
500 contract during the current contract period which will be
501 included in the group contract upon renewal. This subsection
502 does not apply to any increases in benefits. The 45-day notice
503 requirement does shall not apply if benefits are amended,
504 deleted, or limited at the request of the contract holder.
505 (a) At least 60 days before the effective date of any
506 change to a prescription drug formulary during a contract year,
507 a health maintenance organization shall notify:
508 1. Current and prospective subscribers of the change in the
509 formulary, in a readily accessible format on the health
510 maintenance organization’s website; and
511 2. Any subscriber currently receiving coverage for a
512 prescription drug for whom the formulary change modifies
513 coverage and the subscriber’s treating physician. Such
514 notification must be sent electronically and by first-class mail
515 and must include information on the specific drugs involved and
516 a statement that the submission of a notice of medical necessity
517 by the subscriber’s treating physician to the health maintenance
518 organization at least 30 days before the effective date of the
519 formulary change will result in continuation of coverage at the
520 existing level.
521 (b) The notice of medical necessity provided by the
522 treating physician to the health maintenance organization must
523 include a completed one-page form in which the treating
524 physician certifies to the health maintenance organization that
525 the prescription drug for the subscriber is medically necessary
526 as defined in s. 627.732(2). The treating physician shall submit
527 the notice electronically or by first-class mail. The health
528 maintenance organization may provide the treating physician with
529 access to an electronic portal through which the treating
530 physician may electronically submit the notice. By January 1,
531 2027, the commission shall adopt by rule a form for the notice.
532 (c) If the treating physician certifies to the health
533 maintenance organization in accordance with paragraph (b) that
534 the prescription drug is medically necessary for the subscriber,
535 the health maintenance organization:
536 1. Must authorize coverage for the prescribed drug until
537 the end of the contract year, based solely on the treating
538 physician’s certification that the drug is medically necessary;
539 and
540 2. May not modify the coverage related to the covered drug
541 during the contract year by:
542 a. Increasing the out-of-pocket costs for the covered drug;
543 b. Moving the covered drug to a more restrictive tier;
544 c. Denying a subscriber coverage of the drug for which the
545 subscriber has been previously approved for coverage by the
546 health maintenance organization; or
547 d. Limiting or reducing coverage of the drug in any other
548 way, including subjecting it to a new prior authorization or
549 step-therapy requirement.
550 (d) Paragraphs (a), (b), and (c) do not:
551 1. Prohibit the addition of prescription drugs to the list
552 of drugs covered under the contract during the contract year.
553 2. Apply to a grandfathered health plan as defined in s.
554 627.402 or to benefits specified in s. 627.6513.
555 3. Alter or amend s. 465.025, which provides conditions
556 under which a pharmacist may substitute a generically equivalent
557 drug product for a brand name drug product.
558 4. Alter or amend s. 465.0252, which provides conditions
559 under which a pharmacist may dispense a substitute biological
560 product for the prescribed biological product.
561 5. Apply to a Medicaid managed care plan under part IV of
562 chapter 409.
563 (e) A health maintenance organization shall maintain a
564 record of any change in its formulary during a calendar year. By
565 March 1 of each year, a health maintenance organization shall
566 submit to the office a report delineating such changes made in
567 the previous calendar year. The annual report must include, at a
568 minimum:
569 1. A list of all drugs removed from the formulary, along
570 with the date of the removal and the reasons for the removal.
571 2. A list of all drugs moved to a tier resulting in
572 additional out-of-pocket costs to subscribers.
573 3. The number of subscribers impacted by a change in the
574 formulary.
575 4. The number of subscribers notified by the health
576 maintenance organization of a change in the formulary.
577 5. The increased cost, by dollar amount, incurred by
578 subscribers because of such change in the formulary.
579 (f) By May 1 of each year, the office shall:
580 1. Compile the data in the annual reports submitted by
581 health maintenance organizations under paragraph (e) and prepare
582 a report summarizing such data;
583 2. Make the report publicly accessible on its website; and
584 3. Submit the report to the Governor, the President of the
585 Senate, and the Speaker of the House of Representatives.
586 (48)(a) As used in this subsection, the term “cost-sharing
587 requirement” means a dollar limit, a deductible, a copayment,
588 coinsurance, or any other out-of-pocket expense imposed on a
589 subscriber, including, but not limited to, the annual limitation
590 on cost sharing subject to 42 U.S.C. s. 18022.
591 (b)1. Each health maintenance organization issuing,
592 delivering, or renewing a health maintenance contract or
593 certificate in this state which provides prescription drug
594 coverage, or each pharmacy benefit manager on behalf of such
595 health maintenance organization, shall apply any amount paid for
596 a prescription drug by a subscriber or by another person on
597 behalf of the subscriber toward the subscriber’s total
598 contribution to any cost-sharing requirement if the prescription
599 drug:
600 a. Does not have a generic equivalent; or
601 b. Has a generic equivalent and the subscriber has obtained
602 authorization for the prescription drug through any of the
603 following:
604 (I) Prior authorization from the health maintenance
605 organization or pharmacy benefit manager.
606 (II) A step-therapy protocol.
607 (III) The exception or appeal process of the health
608 maintenance organization or pharmacy benefit manager.
609 2. The amount paid by or on behalf of the subscriber which
610 is applied toward the subscriber’s total contribution to any
611 cost-sharing requirement under subparagraph 1. includes, but is
612 not limited to, any payment with or any discount through
613 financial assistance, a manufacturer copay card, a product
614 voucher, or any other reduction in out-of-pocket expenses made
615 by or on behalf of the subscriber for a prescription drug.
616 (c) Each health maintenance organization issuing,
617 delivering, or renewing a health maintenance contract or
618 certificate in this state which provides prescription drug
619 coverage, regardless of whether the prescription drug benefits
620 are administered or managed by the health maintenance
621 organization or by a pharmacy benefit manager on behalf of the
622 health maintenance organization, shall disclose on its website
623 and in every subscriber’s health maintenance contract,
624 certificate, or member handbook issued, delivered, or renewed in
625 this state on or after January 1, 2027, that any amount paid by
626 a subscriber or by another person on behalf of the subscriber
627 must be applied toward the subscriber’s total contribution to
628 any cost-sharing requirement.
629 (d)1. A health maintenance organization issuing,
630 delivering, or renewing a health maintenance contract or
631 certificate in this state which provides prescription drug
632 coverage, regardless of whether the prescription drug benefits
633 are administered or managed by the health maintenance
634 organization or by a pharmacy benefit manager on behalf of the
635 health maintenance organization, shall maintain a record of any
636 third-party payments made or remitted on behalf of a subscriber
637 for prescription drugs, which payments are not applied to the
638 subscriber’s out-of-pocket obligations, including, but not
639 limited to, deductibles, copayments, or coinsurance.
640 2. By March 1 of each year, a health maintenance
641 organization shall submit to the office a report delineating
642 third-party payments, as described in subparagraph 1., which
643 were received in the previous calendar year. The annual report
644 must include, at a minimum:
645 a. A list of all payments received by the health
646 maintenance organization, as described in subparagraph 1., made
647 or remitted by a third party, which must include:
648 (I) The date each payment was made.
649 (II) The prescription drug for which the payment was made.
650 (III) The reason that the payment was not applied to the
651 subscriber’s out-of-pocket obligations.
652 b. The total amount of payments received by the health
653 maintenance organization which were not applied to a
654 subscriber’s out-of-pocket maximum.
655 c. The total number of subscribers for whom a payment was
656 made which was not applied to an out-of-pocket maximum.
657 d. Whether such payments were returned to the third party
658 that submitted the payment.
659 e. The total amount of payments which were not returned to
660 the third party that submitted the payment.
661 (e) This subsection applies to any health maintenance
662 contract, certificate, or member handbook issued, delivered, or
663 renewed in this state on or after January 1, 2027.
664 Section 9. Paragraph (c) is added to subsection (2) of
665 section 641.314, Florida Statutes, to read:
666 641.314 Pharmacy benefit manager contracts.—
667 (2) In addition to the requirements of part VII of chapter
668 626, a contract between a health maintenance organization and a
669 pharmacy benefit manager must require that the pharmacy benefit
670 manager:
671 (c)1. Apply any amount paid by a subscriber or by another
672 person on behalf of the subscriber toward the subscriber’s total
673 contribution to any cost-sharing requirement pursuant to s.
674 641.31(48). This subparagraph applies to any subscriber whose
675 health maintenance contract or certificate is issued, delivered,
676 or renewed in this state on or after January 1, 2027.
677 2. Disclose to every subscriber whose health maintenance
678 contract or certificate is issued, delivered, or renewed in this
679 state on or after January 1, 2027, that the pharmacy benefit
680 manager is required to apply any amount paid by the subscriber
681 or by another person on behalf of the subscriber toward the
682 subscriber’s total contribution to any cost-sharing requirement
683 pursuant to s. 641.31(48).
684 Section 10. Paragraph (o) of subsection (2) of section
685 409.967, Florida Statutes, is amended to read:
686 409.967 Managed care plan accountability.—
687 (2) The agency shall establish such contract requirements
688 as are necessary for the operation of the statewide managed care
689 program. In addition to any other provisions the agency may deem
690 necessary, the contract must require:
691 (o) Transparency.—Managed care plans shall comply with ss.
692 627.6385(4) and 641.54(7) ss. 627.6385(3) and 641.54(7).
693 Section 11. Paragraph (k) of subsection (1) of section
694 641.185, Florida Statutes, is amended to read:
695 641.185 Health maintenance organization subscriber
696 protections.—
697 (1) With respect to the provisions of this part and part
698 III, the principles expressed in the following statements serve
699 as standards to be followed by the commission, the office, the
700 department, and the Agency for Health Care Administration in
701 exercising their powers and duties, in exercising administrative
702 discretion, in administrative interpretations of the law, in
703 enforcing its provisions, and in adopting rules:
704 (k) A health maintenance organization subscriber shall be
705 given a copy of the applicable health maintenance contract,
706 certificate, or member handbook specifying: all the provisions,
707 disclosure, and limitations required pursuant to s. 641.31(1),
708 and (4), and (48); the covered services, including those
709 services, medical conditions, and provider types specified in
710 ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and
711 641.513; and where and in what manner services may be obtained
712 pursuant to s. 641.31(4).
713 Section 12. This act applies to health insurance policies,
714 health benefit plans, and health maintenance contracts entered
715 into or renewed on or after January 1, 2027.
716 Section 13. The Legislature finds that this act fulfills an
717 important state interest.
718 Section 14. This act shall take effect July 1, 2026.