Florida Senate - 2019 COMMITTEE AMENDMENT Bill No. CS for SB 1180 Ì260342vÎ260342 LEGISLATIVE ACTION Senate . House Comm: RCS . 04/08/2019 . . . . ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— 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
shallspecifically 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 shallnot 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.