Florida Senate - 2016 SB 1142
By Senator Hays
11-00928D-16 20161142__
1 A bill to be entitled
2 An act relating to treatments for stable patients;
3 creating s. 627.6465, F.S.; defining terms;
4 prohibiting an insurer or a pharmacy benefits manager
5 from limiting or excluding coverage for a drug for an
6 insured with a certain medical condition under certain
7 conditions; prohibiting certain additional actions
8 with respect to the drug by the insurer or pharmacy
9 benefits manager under the insurance policy; providing
10 an exception; amending s. 627.662, F.S.; providing
11 applicability; amending s. 641.31, F.S.; defining
12 terms; prohibiting a health maintenance contract or a
13 pharmacy benefits manager from limiting or excluding
14 coverage for a drug for a subscriber with a certain
15 medical condition under certain conditions;
16 prohibiting certain additional actions with respect to
17 the drug by the health maintenance contract or
18 pharmacy benefits manager; providing an exception;
19 providing an effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Section 627.6465, Florida Statutes, is created
24 to read:
25 627.6465 Continuity of care for medically stable patients.—
26 (1) As used in this section, the term:
27 (a) “Complex or chronic medical condition” means a
28 physical, behavioral, or developmental condition that does not
29 have a known cure or that can be severely debilitating or fatal
30 if left untreated or undertreated.
31 (b) “Rare medical condition” means a disease or condition
32 that affects fewer than 200,000 individuals in the United
33 States, or approximately 1 in 1,500 individuals worldwide.
34 (2) A pharmacy benefits manager or an individual or group
35 insurance policy that is delivered, issued for delivery,
36 renewed, amended, or continued in this state and that provides
37 medical, major medical, or similar comprehensive coverage may
38 not limit or exclude coverage for a drug for an insured with a
39 complex or chronic medical condition or a rare medical condition
40 if:
41 (a) The drug was previously approved for coverage by the
42 insurer for a medical condition of the insured; and
43 (b) The prescribing provider continues to prescribe the
44 drug for the medical condition, provided that the drug is
45 appropriately prescribed and is considered safe and effective
46 for treating the insured’s medical condition.
47 (3) With respect to a drug for an insured with a complex or
48 chronic medical condition or a rare medical condition which
49 meets the conditions of paragraphs (2)(a) and (2)(b), except
50 during open enrollment periods, a pharmacy benefits manager or
51 an individual or group insurance policy may not:
52 (a) Set forth, by contract, limitations on maximum coverage
53 of prescription drug benefits;
54 (b) Subject the insured to increased out-of-pocket costs;
55 or
56 (c) Move a drug for an insured to a disadvantaged tier, if
57 an individual or group insurance policy or a pharmacy benefits
58 manager uses a formulary with tiers.
59 (4) This section does not prohibit an insurer or a pharmacy
60 benefits manager, by contract, written policy or procedure, or
61 any other agreement or course of conduct, from requiring a
62 pharmacist to effect generic substitutions of prescription
63 drugs.
64 Section 2. Subsection (15) is added to section 627.662,
65 Florida Statutes, to read:
66 627.662 Other provisions applicable.—The following
67 provisions apply to group health insurance, blanket health
68 insurance, and franchise health insurance:
69 (15) Section 627.6465, relating to continuity of care for
70 medically stable patients.
71 Section 3. Subsection (44) is added to section 641.31,
72 Florida Statutes, to read:
73 641.31 Health maintenance contracts.—
74 (44)(a) As used in this subsection, the term:
75 1. “Complex or chronic medical condition” means a physical,
76 behavioral, or developmental condition that does not have a
77 known cure or that can be severely debilitating or fatal if left
78 untreated or undertreated.
79 2. “Rare medical condition” means a disease or condition
80 that affects fewer than 200,000 individuals in the United
81 States, or approximately 1 in 1,500 individuals worldwide.
82 (b) A pharmacy benefits manager or a health maintenance
83 contract that is delivered, issued for delivery, renewed,
84 amended, or continued in this state and that provides medical,
85 major medical, or similar comprehensive coverage may not limit
86 or exclude coverage for a drug for a subscriber with a complex
87 or chronic medical condition or a rare medical condition if:
88 1. The drug was previously approved for coverage by the
89 health maintenance organization for a medical condition of the
90 subscriber; and
91 2. The prescribing provider continues to prescribe the drug
92 for the medical condition, provided that the drug is
93 appropriately prescribed and is considered safe and effective
94 for treating the subscriber’s medical condition.
95 (c) With respect to a drug for a subscriber with a complex
96 or chronic medical condition or a rare medical condition which
97 meets the conditions of subparagraphs (b)1. and (b)2., except
98 during open enrollment periods, a pharmacy benefits manager or a
99 health maintenance contract may not:
100 1. Set forth, by contract, limitations on maximum coverage
101 of prescription drug benefits;
102 2. Subject the subscriber to increased out-of-pocket costs;
103 or
104 3. Move a drug for a subscriber to a disadvantaged tier, if
105 a health maintenance contract or a pharmacy benefits manager
106 uses a formulary with tiers.
107 (d) This subsection does not prohibit a health maintenance
108 organization or a pharmacy benefits manager, by contract,
109 written policy or procedure, or any other agreement or course of
110 conduct, from requiring a pharmacist to effect generic
111 substitutions of prescription drugs.
112 Section 4. This act shall take effect January 1, 2017.