Florida Senate - 2019 CS for CS for SB 1180
By the Committees on Health Policy; and Banking and Insurance;
and Senators Mayfield and Harrell
588-04046-19 20191180c2
1 A bill to be entitled
2 An act relating to prescription drug formulary
3 consumer protection; creating s. 627.42393, F.S.;
4 requiring insurers issuing individual or group health
5 insurance policies to provide certain notices to
6 current and prospective insureds within a certain
7 timeframe before the effective date of any change to a
8 prescription drug formulary during a policy year;
9 specifying requirements for a notice of medical
10 necessity that an insured’s treating physician may
11 submit to the insurer within a certain timeframe;
12 specifying means by which the notice is to be
13 submitted; requiring the Financial Services Commission
14 to adopt a certain rule; specifying a requirement and
15 prohibited acts relating to coverage changes by an
16 insurer if the treating physician provides certain
17 certification; providing construction and
18 applicability; amending s. 627.6699, F.S.; requiring
19 small employer carriers to comply with certain
20 requirements for any change to a prescription drug
21 formulary under the health benefit plan; amending s.
22 641.31, F.S.; requiring health maintenance
23 organizations to provide certain notices to current
24 and prospective subscribers within a certain timeframe
25 before the effective date of any change to a
26 prescription drug formulary during a contract year;
27 specifying requirements for a notice of medical
28 necessity that a subscriber’s treating physician may
29 submit to the health maintenance organization within a
30 certain timeframe; specifying means by which the
31 notice is to be submitted; requiring the commission to
32 adopt a certain rule; specifying a requirement and
33 prohibited acts relating to coverage changes by a
34 health maintenance organization if the treating
35 physician provides certain certification; providing
36 construction and applicability; providing a
37 declaration of important state interest; providing an
38 effective date.
39
40 Be It Enacted by the Legislature of the State of Florida:
41
42 Section 1. Section 627.42393, Florida Statutes, is created
43 to read:
44 627.42393 Health insurance policies; changes to
45 prescription drug formularies; requirements.—
46 (1) At least 60 days before the effective date of any
47 change to a prescription drug formulary during a policy year, an
48 insurer issuing individual or group health insurance policies in
49 this state shall:
50 (a) Provide general notification of the change in the
51 formulary to current and prospective insureds in a readily
52 accessible format on the insurer’s website; and
53 (b) Notify, electronically or by first-class mail, any
54 insured currently receiving coverage for a prescription drug for
55 which the formulary change modifies coverage and the insured’s
56 treating physician, including information on the specific drugs
57 involved and a statement that the submission of a notice of
58 medical necessity by the insured’s treating physician to the
59 insurer at least 30 days before the effective date of the
60 formulary change will result in continuation of coverage at the
61 existing level.
62 (2) The notice provided by the treating physician to the
63 insurer must include a completed one-page form in which the
64 treating physician certifies to the insurer that coverage of the
65 prescription drug for the insured is medically necessary. The
66 treating physician shall submit the notice electronically or by
67 first-class mail. The insurer may provide the treating physician
68 with access to an electronic portal through which the treating
69 physician may electronically file the notice. The commission
70 shall prescribe a form by rule for the notice.
71 (3) If the treating physician certifies to the insurer, in
72 accordance with subsection (2), that the prescription drug is
73 medically necessary for the insured, the insurer:
74 (a) Must authorize coverage for the prescribed drug based
75 solely on the treating physician’s certification that coverage
76 is medically necessary; and
77 (b) May not modify the coverage related to the covered drug
78 by:
79 1. Increasing the out-of-pocket costs for the covered drug;
80 2. Moving the covered drug to a more restrictive tier; or
81 3. Denying an insured coverage of the drug for which the
82 insured has been previously approved for coverage by the
83 insurer.
84 (4) This section does not:
85 (a) Prohibit the addition of prescription drugs to the list
86 of drugs covered under the policy during the policy year.
87 (b) Apply to a grandfathered health plan as defined in s.
88 627.402 or to benefits specified in s. 627.6513(1)-(14).
89 (c) Alter or amend s. 465.025, which provides conditions
90 under which a pharmacist may substitute a generically equivalent
91 drug product for a brand name drug product.
92 (d) Alter or amend s. 465.0252, which provides conditions
93 under which a pharmacist may dispense a substitute biological
94 product for the prescribed biological product.
95 (e) Apply to a Medicaid managed care plan under part IV of
96 chapter 409.
97 Section 2. Paragraph (e) of subsection (5) of section
98 627.6699, Florida Statutes, is amended to read:
99 627.6699 Employee Health Care Access Act.—
100 (5) AVAILABILITY OF COVERAGE.—
101 (e) All health benefit plans issued under this section must
102 comply with the following conditions:
103 1. For employers who have fewer than two employees, a late
104 enrollee may be excluded from coverage for no longer than 24
105 months if he or she was not covered by creditable coverage
106 continually to a date not more than 63 days before the effective
107 date of his or her new coverage.
108 2. Any requirement used by a small employer carrier in
109 determining whether to provide coverage to a small employer
110 group, including requirements for minimum participation of
111 eligible employees and minimum employer contributions, must be
112 applied uniformly among all small employer groups having the
113 same number of eligible employees applying for coverage or
114 receiving coverage from the small employer carrier, except that
115 a small employer carrier that participates in, administers, or
116 issues health benefits pursuant to s. 381.0406 which do not
117 include a preexisting condition exclusion may require as a
118 condition of offering such benefits that the employer has had no
119 health insurance coverage for its employees for a period of at
120 least 6 months. A small employer carrier may vary application of
121 minimum participation requirements and minimum employer
122 contribution requirements only by the size of the small employer
123 group.
124 3. In applying minimum participation requirements with
125 respect to a small employer, a small employer carrier shall not
126 consider as an eligible employee employees or dependents who
127 have qualifying existing coverage in an employer-based group
128 insurance plan or an ERISA qualified self-insurance plan in
129 determining whether the applicable percentage of participation
130 is met. However, a small employer carrier may count eligible
131 employees and dependents who have coverage under another health
132 plan that is sponsored by that employer.
133 4. A small employer carrier shall not increase any
134 requirement for minimum employee participation or any
135 requirement for minimum employer contribution applicable to a
136 small employer at any time after the small employer has been
137 accepted for coverage, unless the employer size has changed, in
138 which case the small employer carrier may apply the requirements
139 that are applicable to the new group size.
140 5. If a small employer carrier offers coverage to a small
141 employer, it must offer coverage to all the small employer’s
142 eligible employees and their dependents. A small employer
143 carrier may not offer coverage limited to certain persons in a
144 group or to part of a group, except with respect to late
145 enrollees.
146 6. A small employer carrier may not modify any health
147 benefit plan issued to a small employer with respect to a small
148 employer or any eligible employee or dependent through riders,
149 endorsements, or otherwise to restrict or exclude coverage for
150 certain diseases or medical conditions otherwise covered by the
151 health benefit plan.
152 7. An initial enrollment period of at least 30 days must be
153 provided. An annual 30-day open enrollment period must be
154 offered to each small employer’s eligible employees and their
155 dependents. A small employer carrier must provide special
156 enrollment periods as required by s. 627.65615.
157 8. A small employer carrier shall comply with s. 627.42393
158 for any change to a prescription drug formulary.
159 Section 3. Subsection (36) of section 641.31, Florida
160 Statutes, is amended to read:
161 641.31 Health maintenance contracts.—
162 (36) Except as provided in paragraphs (a), (b), and (c), a
163 health maintenance organization may increase the copayment for
164 any benefit, or delete, amend, or limit any of the benefits to
165 which a subscriber is entitled under the group contract only,
166 upon written notice to the contract holder at least 45 days in
167 advance of the time of coverage renewal. The health maintenance
168 organization may amend the contract with the contract holder,
169 with such amendment to be effective immediately at the time of
170 coverage renewal. The written notice to the contract holder must
171 shall specifically identify any deletions, amendments, or
172 limitations to any of the benefits provided in the group
173 contract during the current contract period which will be
174 included in the group contract upon renewal. This subsection
175 does not apply to any increases in benefits. The 45-day notice
176 requirement does shall not apply if benefits are amended,
177 deleted, or limited at the request of the contract holder.
178 (a) At least 60 days before the effective date of any
179 change to a prescription drug formulary during a contract year,
180 the health maintenance organization shall:
181 1. Provide general notification of the change in the
182 formulary to current and prospective subscribers in a readily
183 accessible format on the health maintenance organization’s
184 website; and
185 2. Notify, electronically or by first-class mail, any
186 subscriber currently receiving coverage for a prescription drug
187 for which the formulary change modifies coverage and the
188 subscriber’s treating physician, including information on the
189 specific drugs involved and a statement that the submission of a
190 notice of medical necessity by the subscriber’s treating
191 physician to the health maintenance organization at least 30
192 days before the effective date of the formulary change will
193 result in continuation of coverage at the existing level.
194 (b) The notice provided by the treating physician to the
195 insurer must include a completed one-page form in which the
196 treating physician certifies to the health maintenance
197 organization that coverage of the prescription drug for the
198 subscriber is medically necessary. The treating physician shall
199 submit the notice electronically or by first-class mail. The
200 health maintenance organization may provide the treating
201 physician with access to an electronic portal through which the
202 treating physician may electronically file the notice. The
203 commission shall prescribe a form by rule for the notice.
204 (c) If the treating physician certifies to the health
205 maintenance organization, in accordance with paragraph (b), that
206 the prescription drug is medically necessary for the subscriber,
207 the health maintenance organization:
208 1. Must authorize coverage for the prescribed drug based
209 solely on the treating physician’s certification that coverage
210 is medically necessary; and
211 2. May not modify the coverage related to the covered drug
212 by:
213 a. Increasing the out-of-pocket costs for the covered drug;
214 b. Moving the covered drug to a more restrictive tier; or
215 c. Denying a subscriber coverage of the drug for which the
216 subscriber has been previously approved for coverage by the
217 health maintenance organization.
218 (d) Paragraphs (a), (b), and (c) do not:
219 1. Prohibit the addition of prescription drugs to the list
220 of drugs covered under the contract during the contract year.
221 2. Apply to a grandfathered health plan as defined in s.
222 627.402 or to benefits specified in s. 627.6513(1)-(14).
223 3. Alter or amend s. 465.025, which provides conditions
224 under which a pharmacist may substitute a generically equivalent
225 drug product for a brand name drug product.
226 4. Alter or amend s. 465.0252, which provides conditions
227 under which a pharmacist may dispense a substitute biological
228 product for the prescribed biological product.
229 5. Apply to a Medicaid managed care plan under part IV of
230 chapter 409.
231 Section 4. The Legislature finds that this act fulfills an
232 important state interest.
233 Section 5. This act shall take effect January 1, 2020.