1110.12315 Prescription drug program.—The state employees’ prescription drug program is established. This program shall be administered by the Department of Management Services, according to the terms and conditions of the plan as established by the relevant provisions of the annual General Appropriations Act and implementing legislation, subject to the following conditions:(1) The department shall allow prescriptions written by health care providers under the plan to be filled by any licensed pharmacy pursuant to contractual claims-processing provisions. Nothing in this section may be construed as prohibiting a mail order prescription drug program distinct from the service provided by retail pharmacies.
(2) In providing for reimbursement of pharmacies for prescription medicines dispensed to members of the state group health insurance plan and their dependents under the state employees’ prescription drug program:(a) Retail pharmacies participating in the program must be reimbursed at a uniform rate and subject to uniform conditions, according to the terms and conditions of the plan.
2(b) There shall be a 30-day supply limit for prescription card purchases, a 90-day supply limit for maintenance prescription drug purchases, and a 90-day supply limit for mail order or mail order prescription drug purchases. 3(c) The pharmacy dispensing fee shall be negotiated by the department. 3(3) Pharmacy reimbursement rates shall be as follows:(a) For mail order and specialty pharmacies contracting with the department, reimbursement rates shall be as established in the contract.
(b) For retail pharmacies, the reimbursement rate shall be at the same rate as mail order pharmacies under contract with the department.
3(4) The department shall maintain the preferred brand name drug list to be used in the administration of the state employees’ prescription drug program. 3(5) The department shall maintain a list of maintenance drugs.(a) Preferred provider organization health plan members may have prescriptions for maintenance drugs filled up to three times as a 30-day supply through a retail pharmacy; thereafter, prescriptions for the same maintenance drug must be filled as a 90-day supply either through the department’s contracted mail order pharmacy or through a retail pharmacy.
(b) Health maintenance organization health plan members may have prescriptions for maintenance drugs filled as a 90-day supply either through a mail order pharmacy or through a retail pharmacy.
3(6) Copayments made by health plan members for a 90-day supply through a retail pharmacy shall be the same as copayments made for a 90-day supply through the department’s contracted mail order pharmacy. 3(7) The department shall establish the reimbursement schedule for prescription pharmaceuticals dispensed under the program. Reimbursement rates for a prescription pharmaceutical must be based on the cost of the generic equivalent drug if a generic equivalent exists, unless the physician, advanced registered nurse practitioner, or physician assistant prescribing the pharmaceutical clearly states on the prescription that the brand name drug is medically necessary or that the drug product is included on the formulary of drug products that may not be interchanged as provided in chapter 465, in which case reimbursement must be based on the cost of the brand name drug as specified in the reimbursement schedule adopted by the department. 3(8) The department shall conduct a prescription utilization review program. In order to participate in the state employees’ prescription drug program, retail pharmacies dispensing prescription medicines to members of the state group health insurance plan or their covered dependents, or to subscribers or covered dependents of a health maintenance organization plan under the state group insurance program, shall make their records available for this review. 3(9) The department shall implement such additional cost-saving measures and adjustments as may be required to balance program funding within appropriations provided, including a trial or starter dose program and dispensing of long-term-maintenance medication in lieu of acute therapy medication. 3(10) Participating pharmacies must use a point-of-sale device or an online computer system to verify a participant’s eligibility for coverage. The state is not liable for reimbursement of a participating pharmacy for dispensing prescription drugs to any person whose current eligibility for coverage has not been verified by the state’s contracted administrator or by the department. 4(11) Under the state employees’ prescription drug program copayments must be made as follows:(a) Effective January 1, 2013, for the State Group Health Insurance Standard Plan:1. For generic drug with card..........$7.
2. For preferred brand name drug with card..........$30.
3. For nonpreferred brand name drug with card..........$50.
4. For generic mail order drug..........$14.
5. For preferred brand name mail order drug..........$60.
6. For nonpreferred brand name mail order drug..........$100.
(b) Effective January 1, 2006, for the State Group Health Insurance High Deductible Plan:1. Retail coinsurance for generic drug with card..........30%.
2. Retail coinsurance for preferred brand name drug with card..........30%.
3. Retail coinsurance for nonpreferred brand name drug with card..........50%.
4. Mail order coinsurance for generic drug..........30%.
5. Mail order coinsurance for preferred brand name drug..........30%.
6. Mail order coinsurance for nonpreferred brand name drug..........50%.
(c) The department shall create a preferred brand name drug list to be used in the administration of the state employees’ prescription drug program.
History.—s. 53, ch. 92-69; s. 32, ch. 96-399; s. 4, ch. 97-92; ss. 37, 53, ch. 99-228; s. 7, ch. 99-255; s. 62, ch. 2000-171; s. 46, ch. 2001-254; s. 44, ch. 2002-402; s. 39, ch. 2003-399; ss. 33, 76, ch. 2004-269; s. 1, ch. 2004-347; s. 4, ch. 2005-97; s. 4, ch. 2006-18; s. 71, ch. 2010-153; ss. 74, 75, ch. 2011-47; ss. 52, 53, ch. 2012-119; ss. 53, 54, ch. 2013-41; ss. 63, 64, ch. 2014-53; ss. 85, 86, ch. 2015-222; ss. 122, 123, ch. 2016-62; s. 1, ch. 2016-224.
1Note.—A. Section 8, ch. 99-255, provides that “[t]he Department of Management Services shall not implement a prior authorization program or a restricted formulary program that restricts a non-HMO enrollee’s access to prescription drugs beyond the provisions of [subsection (7)] related specifically to generic equivalents for prescriptions and the provisions in [subsection (9)] related specifically to starter dose programs or the dispensing of long-term maintenance medications. The prior authorization program expanded pursuant to section 8 of the 1998-1999 General Appropriations Act is hereby terminated. If this section conflicts with any General Appropriations Act or any act implementing a General Appropriations Act, the Legislature intends that the provisions of this section shall prevail. This section shall take effect upon becoming law.”
B. Section 122, ch. 2016-62, reenacted s. 110.12315 “[i]n order to implement section 8 of the 2016-2017 General Appropriations Act.”
2Note.—Section 123(1), ch. 2016-62, provides that “[t]he amendment to s. 110.12315(2)(b), Florida Statutes, as carried forward by this act from chapter 2014-53, Laws of Florida, expires July 1, 2017, and the text of that paragraph shall revert to that in existence on June 30, 2012, except that any amendments to such text enacted other than by this act shall be preserved and continue to operate to the extent that such amendments are not dependent upon the portions of text which expire pursuant to this section.” Effective July 1, 2017, paragraph (2)(b), as amended by s. 123(1), ch. 2016-62, will read:(b) There shall be a 30-day supply limit for prescription card purchases and 90-day supply limit for mail order or mail order prescription drug purchases.
3Note.—Section 123(2), ch. 2016-62, provides that “[t]he amendments to s. 110.12315(2)(c) and (3)-(6), Florida Statutes, as carried forward by this act from chapter 2014-53, Laws of Florida, expire July 1, 2017, and the text and numbering of those provisions shall revert to that in existence on June 30, 2014, except that any amendments to such text enacted other than by this act shall be preserved and continue to operate to the extent that such amendments are not dependent upon the portions of text that expire pursuant to this section.” Effective July 1, 2017, paragraph (2)(c) is amended, subsections (3)-(6) are repealed, and subsections (7)-(10) are amended and renumbered as subsections (3)-(6) by s. 123(2), ch. 2016-62. As amended by s. 123(2), ch. 2016-62, and s. 1, ch. 2016-224, paragraph (2)(c) and subsections (3)-(6) will read:(c) The current pharmacy dispensing fee remains in effect.
(3) The Department of Management Services shall establish the reimbursement schedule for prescription pharmaceuticals dispensed under the program. Reimbursement rates for a prescription pharmaceutical must be based on the cost of the generic equivalent drug if a generic equivalent exists, unless the physician, advanced registered nurse practitioner, or physician assistant prescribing the pharmaceutical clearly states on the prescription that the brand name drug is medically necessary or that the drug product is included on the formulary of drug products that may not be interchanged as provided in chapter 465, in which case reimbursement must be based on the cost of the brand name drug as specified in the reimbursement schedule adopted by the Department of Management Services.
(4) The Department of Management Services shall conduct a prescription utilization review program. In order to participate in the state employees’ prescription drug program, retail pharmacies dispensing prescription medicines to members of the state group health insurance plan or their covered dependents, or to subscribers or covered dependents of a health maintenance organization plan under the state group insurance program, shall make their records available for this review.
(5) The Department of Management Services shall implement such additional cost-saving measures and adjustments as may be required to balance program funding within appropriations provided, including a trial or starter dose program and dispensing of long-term-maintenance medication in lieu of acute therapy medication.
(6) Participating pharmacies must use a point-of-sale device or an online computer system to verify a participant’s eligibility for coverage. The state is not liable for reimbursement of a participating pharmacy for dispensing prescription drugs to any person whose current eligibility for coverage has not been verified by the state’s contracted administrator or by the Department of Management Services.
4Note.—Section 123(3), ch. 2016-62, provides that “[t]he amendment to s. 110.12315(7), Florida Statutes, as carried forward by this act from chapter 2014-53, Laws of Florida, expires July 1, 2017, and shall revert to the text of that subsection in existence on December 31, 2010, except that any amendments to such text enacted other than by this act shall be preserved and continue to operate to the extent that such amendments are not dependent upon the portions of text which expire pursuant to this section.” Effective July 1, 2017, subsection (7), as amended and renumbered from subsection (11) by s. 123(3), ch. 2016-62, will read:(7) Under the state employees’ prescription drug program copayments must be made as follows:
(a) Effective January 1, 2006, for the State Group Health Insurance Standard Plan:
1. For generic drug with card..........$10.
2. For preferred brand name drug with card..........$25.
3. For nonpreferred brand name drug with card..........$40.
4. For generic mail order drug..........$20.
5. For preferred brand name mail order drug..........$50.
6. For nonpreferred brand name mail order drug..........$80.
(b) Effective January 1, 2006, for the State Group Health Insurance High Deductible Plan:
1. Retail coinsurance for generic drug with card..........30%.
2. Retail coinsurance for preferred brand name drug with card..........30%.
3. Retail coinsurance for nonpreferred brand name drug with card..........50%.
4. Mail order coinsurance for generic drug..........30%.
5. Mail order coinsurance for preferred brand name drug..........30%.
6. Mail order coinsurance for nonpreferred brand name drug..........50%.
(c) The Department of Management Services shall create a preferred brand name drug list to be used in the administration of the state employees’ prescription drug program.
