Bill Text: FL S0742 | 2022 | Regular Session | Introduced
Bill Title: Pharmacies and Pharmacy Benefit Managers
Spectrum: Partisan Bill (Republican 1-0)
Status: (Failed) 2022-03-14 - Died in Banking and Insurance [S0742 Detail]
Download: Florida-2022-S0742-Introduced.html
Florida Senate - 2022 SB 742
By Senator Rodriguez
39-00799A-22 2022742__
1 A bill to be entitled
2 An act relating to pharmacies and pharmacy benefit
3 managers; amending s. 409.967, F.S.; requiring that
4 certain pharmacies be included in managed care plan
5 pharmacy networks; requiring managed care plans to
6 publish the Agency for Health Care Administration’s
7 preferred drug list, rather than any prescribed drug
8 formulary; requiring plans to update the list within a
9 certain timeframe after the agency makes a change;
10 amending s. 409.973, F.S.; providing requirements for
11 managed care plans using pharmacy benefit managers;
12 requiring the agency to seek a plan amendment or
13 federal waiver by a specified date; amending s.
14 409.975, F.S.; conforming a provision to changes made
15 by the act; amending s. 624.3161, F.S.; requiring the
16 Office of Insurance Regulation to examine pharmacy
17 benefit managers under certain circumstances;
18 specifying that certain examination costs are payable
19 by persons examined; amending 624.490, F.S.;
20 authorizing the Office of Insurance Regulation to
21 suspend or revoke a pharmacy benefit manager’s
22 registration or impose a fine for specified
23 violations; defining the terms “spread pricing” and
24 “affiliate”; transferring, renumbering, and amending
25 s. 465.1885, F.S.; revising the entities conducting
26 pharmacy audits to which certain requirements and
27 restrictions apply; authorizing audited pharmacies to
28 appeal certain findings; providing that health
29 insurers and health maintenance organizations that
30 transfer a certain payment obligation to pharmacy
31 benefit managers remain responsible for specified
32 violations; amending s. 627.6131, F.S.; revising the
33 definition of the term “claim” and defining the term
34 “pharmacy claim”; providing an exception to
35 applicability; making technical changes; prohibiting
36 pharmacy benefit managers from charging pharmacists
37 and pharmacies certain fees and from retroactively
38 denying, holding back, or reducing payments for
39 covered claims; requiring that the Department of
40 Financial Services have access to certain records,
41 data, and information; providing applicability;
42 amending ss. 627.64741, 627.6572, and 641.314, F.S.;
43 revising the definition of the term “maximum allowable
44 cost”; requiring that the department have access to
45 certain records, data, and information; providing that
46 pharmacy benefit managers that violate certain
47 provisions are subject to administrative penalties;
48 authorizing the Financial Services Commission to adopt
49 rules; revising applicability; amending s. 627.6699,
50 F.S.; requiring certain health benefit plans covering
51 small employers to comply with specified provisions;
52 amending s. 641.3155, F.S.; revising the definition of
53 the term “claim” and providing a definition for the
54 term “pharmacy claim”; making technical changes;
55 prohibiting pharmacy benefit managers from charging
56 pharmacists and pharmacies certain fees and from
57 retroactively denying, holding back, or reducing
58 payments for covered claims; requiring that the
59 department have access to certain records, data, and
60 information; providing applicability; providing an
61 effective date.
62
63 Be It Enacted by the Legislature of the State of Florida:
64
65 Section 1. Paragraph (c) of subsection (2) of section
66 409.967, Florida Statutes, is amended to read:
67 409.967 Managed care plan accountability.—
68 (2) The agency shall establish such contract requirements
69 as are necessary for the operation of the statewide managed care
70 program. In addition to any other provisions the agency may deem
71 necessary, the contract must require:
72 (c) Access.—
73 1. The agency shall establish specific standards for the
74 number, type, and regional distribution of providers in managed
75 care plan networks to ensure access to care for both adults and
76 children. Each plan must maintain a regionwide network of
77 providers in sufficient numbers to meet the access standards for
78 specific medical services for all recipients enrolled in the
79 plan. Any pharmacy willing to accept reasonable terms and
80 conditions established by the agency shall be included in a
81 managed care plan’s pharmacy network. The exclusive use of mail
82 order pharmacies may not be sufficient to meet network access
83 standards. Consistent with the standards established by the
84 agency, provider networks may include providers located outside
85 the region. A plan may contract with a new hospital facility
86 before the date the hospital becomes operational if the hospital
87 has commenced construction, will be licensed and operational by
88 January 1, 2013, and a final order has issued in any civil or
89 administrative challenge. Each plan shall establish and maintain
90 an accurate and complete electronic database of contracted
91 providers, including information about licensure or
92 registration, locations and hours of operation, specialty
93 credentials and other certifications, specific performance
94 indicators, and such other information as the agency deems
95 necessary. The database must be available online to both the
96 agency and the public and have the capability to compare the
97 availability of providers to network adequacy standards and to
98 accept and display feedback from each provider’s patients. Each
99 plan shall submit quarterly reports to the agency identifying
100 the number of enrollees assigned to each primary care provider.
101 The agency shall conduct, or contract for, systematic and
102 continuous testing of the provider network databases maintained
103 by each plan to confirm accuracy, confirm that behavioral health
104 providers are accepting enrollees, and confirm that enrollees
105 have access to behavioral health services.
106 2. Each managed care plan must publish the agency’s any
107 prescribed drug formulary or preferred drug list on the plan’s
108 website in a manner that is accessible to and searchable by
109 enrollees and providers. The plan must update the list within 24
110 hours after the agency makes making a change. Each plan must
111 ensure that the prior authorization process for prescribed drugs
112 is readily accessible to health care providers, including
113 posting appropriate contact information on its website and
114 providing timely responses to providers. For Medicaid recipients
115 diagnosed with hemophilia who have been prescribed anti
116 hemophilic-factor replacement products, the agency shall provide
117 for those products and hemophilia overlay services through the
118 agency’s hemophilia disease management program.
119 3. Managed care plans, and their fiscal agents or
120 intermediaries, must accept prior authorization requests for any
121 service electronically.
122 4. Managed care plans serving children in the care and
123 custody of the Department of Children and Families must maintain
124 complete medical, dental, and behavioral health encounter
125 information and participate in making such information available
126 to the department or the applicable contracted community-based
127 care lead agency for use in providing comprehensive and
128 coordinated case management. The agency and the department shall
129 establish an interagency agreement to provide guidance for the
130 format, confidentiality, recipient, scope, and method of
131 information to be made available and the deadlines for
132 submission of the data. The scope of information available to
133 the department shall be the data that managed care plans are
134 required to submit to the agency. The agency shall determine the
135 plan’s compliance with standards for access to medical, dental,
136 and behavioral health services; the use of medications; and
137 followup on all medically necessary services recommended as a
138 result of early and periodic screening, diagnosis, and
139 treatment.
140 Section 2. Subsection (7) is added to section 409.973,
141 Florida Statutes, to read:
142 409.973 Benefits.—
143 (7) PRESCRIPTION DRUG BENEFITS.—
144 (a) Each plan operating in the managed medical assistance
145 program using a pharmacy benefit manager shall:
146 1. Ensure the pharmacy benefit manager complies with the
147 requirements of s. 624.490.
148 2. Require the pharmacy benefit manager to reimburse
149 Medicaid pharmacy providers and providers enrolled as dispensing
150 practitioners for drugs dispensed in an amount equal to the
151 National Average Drug Acquisition Cost (NADAC) plus a
152 professional dispensing fee of $10.60. If the NADAC is
153 unavailable, the pharmacy benefit manager must reimburse the
154 providers in an amount equal to the wholesale acquisition cost
155 plus a professional dispensing fee of $10.60.
156 3. Require the pharmacy benefit manager to use preferred
157 drug lists established by the agency.
158 (b) The agency shall seek any state plan amendment or
159 federal waiver necessary to implement this subsection no later
160 than December 31, 2022.
161 Section 3. Subsection (1) of section 409.975, Florida
162 Statutes, is amended to read:
163 409.975 Managed care plan accountability.—In addition to
164 the requirements of s. 409.967, plans and providers
165 participating in the managed medical assistance program shall
166 comply with the requirements of this section.
167 (1) PROVIDER NETWORKS.—Managed care plans must develop and
168 maintain provider networks that meet the medical needs of their
169 enrollees in accordance with standards established pursuant to
170 s. 409.967(2)(c). Except as provided in this section and in s.
171 409.967(2)(c), managed care plans may limit the providers in
172 their networks based on credentials, quality indicators, and
173 price.
174 (a) Plans must include all providers in the region that are
175 classified by the agency as essential Medicaid providers, unless
176 the agency approves, in writing, an alternative arrangement for
177 securing the types of services offered by the essential
178 providers. Providers are essential for serving Medicaid
179 enrollees if they offer services that are not available from any
180 other provider within a reasonable access standard, or if they
181 provided a substantial share of the total units of a particular
182 service used by Medicaid patients within the region during the
183 last 3 years and the combined capacity of other service
184 providers in the region is insufficient to meet the total needs
185 of the Medicaid patients. The agency may not classify physicians
186 and other practitioners as essential providers. The agency, at a
187 minimum, shall determine which providers in the following
188 categories are essential Medicaid providers:
189 1. Federally qualified health centers.
190 2. Statutory teaching hospitals as defined in s.
191 408.07(46).
192 3. Hospitals that are trauma centers as defined in s.
193 395.4001(15).
194 4. Hospitals located at least 25 miles from any other
195 hospital with similar services.
196
197 Managed care plans that have not contracted with all essential
198 providers in the region as of the first date of recipient
199 enrollment, or with whom an essential provider has terminated
200 its contract, must negotiate in good faith with such essential
201 providers for 1 year or until an agreement is reached, whichever
202 is first. Payments for services rendered by a nonparticipating
203 essential provider shall be made at the applicable Medicaid rate
204 as of the first day of the contract between the agency and the
205 plan. A rate schedule for all essential providers shall be
206 attached to the contract between the agency and the plan. After
207 1 year, managed care plans that are unable to contract with
208 essential providers shall notify the agency and propose an
209 alternative arrangement for securing the essential services for
210 Medicaid enrollees. The arrangement must rely on contracts with
211 other participating providers, regardless of whether those
212 providers are located within the same region as the
213 nonparticipating essential service provider. If the alternative
214 arrangement is approved by the agency, payments to
215 nonparticipating essential providers after the date of the
216 agency’s approval shall equal 90 percent of the applicable
217 Medicaid rate. Except for payment for emergency services, if the
218 alternative arrangement is not approved by the agency, payment
219 to nonparticipating essential providers shall equal 110 percent
220 of the applicable Medicaid rate.
221 (b) Certain providers are statewide resources and essential
222 providers for all managed care plans in all regions. All managed
223 care plans must include these essential providers in their
224 networks. Statewide essential providers include:
225 1. Faculty plans of Florida medical schools.
226 2. Regional perinatal intensive care centers as defined in
227 s. 383.16(2).
228 3. Hospitals licensed as specialty children’s hospitals as
229 defined in s. 395.002(28).
230 4. Accredited and integrated systems serving medically
231 complex children which comprise separately licensed, but
232 commonly owned, health care providers delivering at least the
233 following services: medical group home, in-home and outpatient
234 nursing care and therapies, pharmacy services, durable medical
235 equipment, and Prescribed Pediatric Extended Care.
236
237 Managed care plans that have not contracted with all statewide
238 essential providers in all regions as of the first date of
239 recipient enrollment must continue to negotiate in good faith.
240 Payments to physicians on the faculty of nonparticipating
241 Florida medical schools shall be made at the applicable Medicaid
242 rate. Payments for services rendered by regional perinatal
243 intensive care centers shall be made at the applicable Medicaid
244 rate as of the first day of the contract between the agency and
245 the plan. Except for payments for emergency services, payments
246 to nonparticipating specialty children’s hospitals shall equal
247 the highest rate established by contract between that provider
248 and any other Medicaid managed care plan.
249 (c) After 12 months of active participation in a plan’s
250 network, the plan may exclude any essential provider from the
251 network for failure to meet quality or performance criteria. If
252 the plan excludes an essential provider from the plan, the plan
253 must provide written notice to all recipients who have chosen
254 that provider for care. The notice shall be provided at least 30
255 days before the effective date of the exclusion. For purposes of
256 this paragraph, the term “essential provider” includes providers
257 determined by the agency to be essential Medicaid providers
258 under paragraph (a) and the statewide essential providers
259 specified in paragraph (b).
260 (d) The applicable Medicaid rates for emergency services
261 paid by a plan under this section to a provider with which the
262 plan does not have an active contract shall be determined
263 according to s. 409.967(2)(b).
264 (e) Each managed care plan may offer a network contract to
265 each home medical equipment and supplies provider in the region
266 which meets quality and fraud prevention and detection standards
267 established by the plan and which agrees to accept the lowest
268 price previously negotiated between the plan and another such
269 provider.
270 Section 4. Subsections (1) and (3) of section 624.3161,
271 Florida Statutes, are amended to read:
272 624.3161 Market conduct examinations.—
273 (1) As often as it deems necessary, the office shall
274 examine each pharmacy benefit manager as defined in s. 624.490;
275 each licensed rating organization;, each advisory organization;,
276 each group, association, carrier, as defined in s. 440.02, or
277 other organization of insurers which engages in joint
278 underwriting or joint reinsurance;, and each authorized insurer
279 transacting in this state any class of insurance to which the
280 provisions of chapter 627 are applicable. The examination shall
281 be for the purpose of ascertaining compliance by the person
282 examined with the applicable provisions of chapters 440, 624,
283 626, 627, and 635.
284 (3) The examination may be conducted by an independent
285 professional examiner under contract to the office, in which
286 case payment shall be made directly to the contracted examiner
287 by the insurer or person examined in accordance with the rates
288 and terms agreed to by the office and the examiner.
289 Section 5. Present subsection (6) of section 624.490,
290 Florida Statutes, is redesignated as subsection (7), and a new
291 subsection (6) is added to that section, to read:
292 624.490 Registration of pharmacy benefit managers.—
293 (6) The office may suspend or revoke a pharmacy benefit
294 manager’s registration or impose a fine if it finds the pharmacy
295 benefit manager:
296 (a) Breached its fiduciary duty to the health insurer or
297 health maintenance organization.
298 (b) Used spread pricing. For purposes of this subsection,
299 “spread pricing” means any technique by which a pharmacy benefit
300 manager charges or claims an amount from a health insurer or
301 health maintenance organization for pharmacy or pharmacist
302 services, including payment for a prescription drug, which is
303 different than the amount the pharmacy benefit manager pays to
304 the pharmacy or pharmacist that provided the services.
305 (c) Reduced payment for pharmacy or pharmacist services,
306 directly or indirectly, by creating, imposing, or establishing
307 direct or indirect remuneration fees, generic effective rates,
308 dispensing effective rates, brand effective rates, any other
309 effective rates, in-network fees, performance fees, pre
310 adjudication fees, post-adjudication fees, or any other
311 mechanism that reduces, or aggregately reduces, payment for
312 pharmacy or pharmacist services.
313 (d) Required or influenced an insured or enrollee to use an
314 affiliate. For purposes of this subsection, “affiliate” means a
315 pharmacy in which a pharmacy benefit manager, directly or
316 indirectly, has an investment, financial, or ownership interest;
317 a pharmacy that, directly or indirectly, has an investment,
318 financial, or ownership interest in the pharmacy benefit
319 manager; or a pharmacy that is under common ownership, directly
320 or indirectly, as the pharmacy benefit manager.
321 (e) Required or influenced an insured or enrollee to use a
322 mail-order pharmacy.
323 (f) Excluded a pharmacy that was willing to accept the
324 plan’s terms and reimbursement, and that met the plan’s
325 credentialing requirements and quality standards, from
326 participating in the plan.
327 (g) Violated s. 624.491, s. 627.6131, s. 627.64741, s.
328 627.6572, s. 641.314, or s. 641.3155.
329 Section 6. Section 465.1885, Florida Statutes, is
330 transferred, renumbered as section 624.491, Florida Statutes,
331 and amended to read:
332 624.491 465.1885 Pharmacy audits; rights.—
333 (1) Health insurers, health maintenance organizations, and
334 pharmacy benefit managers shall comply with the requirements of
335 this section when auditing the records of a pharmacy licensed
336 under chapter 465. The person or entity conducting such audit
337 must If an audit of the records of a pharmacy licensed under
338 this chapter is conducted directly or indirectly by a managed
339 care company, an insurance company, a third-party payor, a
340 pharmacy benefit manager, or an entity that represents
341 responsible parties such as companies or groups, referred to as
342 an “entity” in this section, the pharmacy has the following
343 rights:
344 (a) Except as provided in subsection (3), notify the
345 pharmacy To be notified at least 7 calendar days before the
346 initial onsite audit for each audit cycle.
347 (b) Not schedule an To have the onsite audit during
348 scheduled after the first 3 calendar days of a month unless the
349 pharmacist consents otherwise.
350 (c) Limit the duration of To have the audit period limited
351 to 24 months after the date a claim is submitted to or
352 adjudicated by the entity.
353 (d) In the case of To have an audit that requires clinical
354 or professional judgment, conduct the audit in consultation
355 with, or allow the audit to be conducted by, or in consultation
356 with a pharmacist.
357 (e) Allow the pharmacy to use the written and verifiable
358 records of a hospital, physician, or other authorized
359 practitioner, which are transmitted by any means of
360 communication, to validate the pharmacy records in accordance
361 with state and federal law.
362 (f) Reimburse the pharmacy To be reimbursed for a claim
363 that was retroactively denied for a clerical error,
364 typographical error, scrivener’s error, or computer error if the
365 prescription was properly and correctly dispensed, unless a
366 pattern of such errors exists, fraudulent billing is alleged, or
367 the error results in actual financial loss to the entity.
368 (g) Provide the pharmacy with a copy of To receive the
369 preliminary audit report within 120 days after the conclusion of
370 the audit.
371 (h) Allow the pharmacy to produce documentation to address
372 a discrepancy or audit finding within 10 business days after the
373 preliminary audit report is delivered to the pharmacy.
374 (i) Provide the pharmacy with a copy of To receive the
375 final audit report within 6 months after receipt of receiving
376 the preliminary audit report.
377 (j) Calculate any To have recoupment or penalties based on
378 actual overpayments and not according to the accounting practice
379 of extrapolation.
380 (2) The rights contained in This section does do not apply
381 to:
382 (a) Audits in which suspected fraudulent activity or other
383 intentional or willful misrepresentation is evidenced by a
384 physical review, review of claims data or statements, or other
385 investigative methods;
386 (b) Audits of claims paid for by federally funded programs;
387 or
388 (c) Concurrent reviews or desk audits that occur within 3
389 business days after of transmission of a claim and where no
390 chargeback or recoupment is demanded.
391 (3) An entity that audits a pharmacy located within a
392 Health Care Fraud Prevention and Enforcement Action Team (HEAT)
393 Task Force area designated by the United States Department of
394 Health and Human Services and the United States Department of
395 Justice may dispense with the notice requirements of paragraph
396 (1)(a) if such pharmacy has been a member of a credentialed
397 provider network for less than 12 months.
398 (4) Pursuant to s. 408.7057, and after receipt of the final
399 audit report issued by the health insurer, health maintenance
400 organization, or pharmacy benefit manager, a pharmacy may appeal
401 the findings of the final audit as to whether a claim payment is
402 due and as to the amount of a claim payment.
403 (5) A health insurer or health maintenance organization
404 that, under terms of a contract, transfers to a pharmacy benefit
405 manager the obligation to pay any pharmacy licensed under
406 chapter 465 for any pharmacy benefit claims arising from
407 services provided to or for the benefit of any insured or
408 subscriber remains responsible for any violations of this
409 section, s. 627.6131, or s. 641.3155, as applicable.
410 Section 7. Present subsections (18) and (19) of section
411 627.6131, Florida Statutes, are redesignated as subsections (19)
412 and (20), respectively, a new subsection (18) is added to that
413 section, and subsections (2), (15), (16), and (17) of that
414 section are amended, to read:
415 627.6131 Payment of claims.—
416 (2)(a) As used in this section, the term “claim” for a
417 noninstitutional provider means a paper or electronic billing
418 instrument submitted to the insurer’s designated location that
419 consists of the HCFA 1500 data set, or its successor, that has
420 all mandatory entries for a physician licensed under chapter
421 458, chapter 459, chapter 460, chapter 461, or chapter 463, or
422 psychologists licensed under chapter 490 or any appropriate
423 billing instrument that has all mandatory entries for any other
424 noninstitutional provider. For institutional providers, the term
425 “claim” means a paper or electronic billing instrument submitted
426 to the insurer’s designated location that consists of the UB-92
427 data set or its successor with entries stated as mandatory by
428 the National Uniform Billing Committee.
429 (b) However, if the context so indicates, the term “claim”
430 or “pharmacy claim” means a paper or electronic billing
431 instrument submitted to a pharmacy benefit manager acting on
432 behalf of a health insurer.
433 (15) Except for subsection (18), this section is applicable
434 only to a major medical expense health insurance policy as
435 defined in s. 627.643(2)(e) offered by a group or an individual
436 health insurer licensed pursuant to chapter 624, including a
437 preferred provider policy under s. 627.6471 and an exclusive
438 provider organization under s. 627.6472 or a group or individual
439 insurance contract that only provides direct payments to
440 dentists for enumerated dental services.
441 (16) Notwithstanding paragraph (4)(b), if where an
442 electronic pharmacy claim is submitted to a pharmacy benefit
443 benefits manager acting on behalf of a health insurer, the
444 pharmacy benefit benefits manager must shall, within 30 days
445 after of receipt of the claim, pay the claim or notify a
446 provider or designee if a claim is denied or contested. Notice
447 of the insurer’s action on the claim and payment of the claim is
448 considered to be made on the date the notice or payment was
449 mailed or electronically transferred.
450 (17) Notwithstanding paragraph (5)(a), if effective
451 November 1, 2003, where a nonelectronic pharmacy claim is
452 submitted to a pharmacy benefit benefits manager acting on
453 behalf of a health insurer, the pharmacy benefit benefits
454 manager must shall provide acknowledgment of receipt of the
455 claim within 30 days after receipt of the claim to the provider
456 or provide a provider within 30 days after receipt with
457 electronic access to the status of a submitted claim.
458 (18)(a) A pharmacy benefit manager may not:
459 1. Charge a pharmacist or pharmacy a fee related to the
460 payment of a pharmacy claim, including, but not limited to, a
461 fee for:
462 a. The submission of the claim;
463 b. The pharmacist’s or pharmacy’s enrollment or
464 participation in a retail pharmacy network; or
465 c. The processing or transmission of the claim; or
466 2. Retroactively deny, hold back, or reduce payment for a
467 covered claim after payment for the claim.
468 (b) The department shall have access to all financial and
469 utilization records in the possession of, and data and
470 information used by, a pharmacy benefit manager in relation to
471 the pharmacy benefit management services provided to health
472 insurers or other providers using the pharmacy benefit
473 management services in this state.
474 (c) This subsection applies to contracts entered into,
475 amended, or renewed on or after January 1, 2023.
476 Section 8. Present subsection (5) of section 627.64741,
477 Florida Statutes, is redesignated as subsection (8) and amended,
478 a new subsection (5) and subsections (6) and (7) are added to
479 that section, and subsection (1) of that section is amended, to
480 read:
481 627.64741 Pharmacy benefit manager contracts.—
482 (1) As used in this section, the term:
483 (a) “Maximum allowable cost” means the per-unit amount that
484 a pharmacy benefit manager reimburses a pharmacist for a
485 prescription drug and that:,
486 1. Is as specified at the time of claim processing and
487 directly or indirectly reported on the initial remittance advice
488 of an adjudicated claim for a generic drug, brand name drug,
489 biological product, or specialty drug;
490 2. Must be based on pricing published in the Medi-Span
491 Master Drug Database or, if the pharmacy benefit manager uses
492 only First Databank (FDB) MedKnowledge, on pricing published in
493 FDB MedKnowledge;
494 3. Excludes excluding dispensing fees; and,
495 4. Is determined before prior to the application of
496 copayments, coinsurance, and other cost-sharing charges, if any.
497 (b) “Pharmacy benefit manager” means a person or entity
498 doing business in this state which contracts to administer or
499 manage prescription drug benefits on behalf of a health insurer
500 to residents of this state.
501 (5) The department shall have access to all financial and
502 utilization records in the possession of, and data and
503 information used by, a pharmacy benefit manager in relation to
504 the pharmacy benefit management services provided to health
505 insurers or other providers using the pharmacy benefit
506 management services in this state.
507 (6) A pharmacy benefit manager that violates the contract
508 provisions required by this section is subject to the penalties
509 provided in s. 624.490(6).
510 (7) The commission may adopt rules to administer this
511 section.
512 (8)(5) This section applies to contracts entered into,
513 amended, or renewed on or after January 1, 2023 July 1, 2018.
514 Section 9. Present subsection (5) of section 627.6572,
515 Florida Statutes, is redesignated as subsection (8) and amended,
516 a new subsection (5) and subsections (6) and (7) are added to
517 that section, and subsection (1) of that section is amended, to
518 read:
519 627.6572 Pharmacy benefit manager contracts.—
520 (1) As used in this section, the term:
521 (a) “Maximum allowable cost” means the per-unit amount that
522 a pharmacy benefit manager reimburses a pharmacist for a
523 prescription drug and that:,
524 1. Is as specified at the time of claim processing and
525 directly or indirectly reported on the initial remittance advice
526 of an adjudicated claim for a generic drug, brand name drug,
527 biological product, or specialty drug;
528 2. Must be based on pricing published in the Medi-Span
529 Master Drug Database or, if the pharmacy benefit manager uses
530 only First Databank (FDB) MedKnowledge, on pricing published in
531 FDB MedKnowledge;
532 3. Excludes excluding dispensing fees; and,
533 4. Is determined before prior to the application of
534 copayments, coinsurance, and other cost-sharing charges, if any.
535 (b) “Pharmacy benefit manager” means a person or entity
536 doing business in this state which contracts to administer or
537 manage prescription drug benefits on behalf of a health insurer
538 to residents of this state.
539 (5) The department shall have access to all financial and
540 utilization records in the possession of, and data and
541 information used by, a pharmacy benefit manager in relation to
542 the pharmacy benefit management services provided to health
543 insurers or other providers using the pharmacy benefit
544 management services in this state.
545 (6) A pharmacy benefit manager that violates the contract
546 provisions required by this section is subject to the penalties
547 provided in s. 624.490(6).
548 (7) The commission may adopt rules to administer this
549 section.
550 (8)(5) This section applies to contracts entered into,
551 amended, or renewed on or after January 1, 2023 July 1, 2018.
552 Section 10. Paragraph (h) is added to subsection (5) of
553 section 627.6699, Florida Statutes, to read:
554 627.6699 Employee Health Care Access Act.—
555 (5) AVAILABILITY OF COVERAGE.—
556 (h) A health benefit plan covering small employers which is
557 delivered, issued, amended, or renewed in this state on or after
558 January 1, 2023, must comply with s. 627.6572.
559 Section 11. Present subsection (5) of section 641.314,
560 Florida Statutes, is redesignated as subsection (8) and amended,
561 a new subsection (5) and subsections(6) and (7) are added to
562 that section, and subsection (1) of that section is amended, to
563 read:
564 641.314 Pharmacy benefit manager contracts.—
565 (1) As used in this section, the term:
566 (a) “Maximum allowable cost” means the per-unit amount that
567 a pharmacy benefit manager reimburses a pharmacist for a
568 prescription drug and that:,
569 1. Is as specified at the time of claim processing and
570 directly or indirectly reported on the initial remittance advice
571 of an adjudicated claim for a generic drug, brand name drug,
572 biological product, or specialty drug;
573 2. Must be based on pricing published in the Medi-Span
574 Master Drug Database or, if the pharmacy benefit manager uses
575 only First Databank (FDB) MedKnowledge, on pricing published in
576 FDB MedKnowledge;
577 3. Excludes Excluding dispensing fees; and,
578 4. Is determined before prior to the application of
579 copayments, coinsurance, and other cost-sharing charges, if any.
580 (b) “Pharmacy benefit manager” means a person or entity
581 doing business in this state which contracts to administer or
582 manage prescription drug benefits on behalf of a health
583 maintenance organization to residents of this state.
584 (5) The department shall have access to all financial and
585 utilization records in the possession of, and data and
586 information used by, a pharmacy benefit manager in relation to
587 the pharmacy benefit management services provided to health
588 insurers or other providers using the pharmacy benefit
589 management services in this state.
590 (6) A pharmacy benefit manager that violates the contract
591 provisions required by this section is subject to the penalties
592 provided in s. 624.490(6).
593 (7) The commission may adopt rules to administer this
594 section.
595 (8)(5) This section applies to contracts entered into,
596 amended, or renewed on or after January 1, 2023 July 1, 2018.
597 Section 12. Present subsections (16) and (17) of section
598 641.3155, Florida Statutes, are redesignated as subsections (17)
599 and (18), respectively, a new subsection (16) is added to that
600 section, and subsections (1), (14), and (15) of that section are
601 amended, to read:
602 641.3155 Prompt payment of claims.—
603 (1)(a) As used in this section, the term “claim” for a
604 noninstitutional provider means a paper or electronic billing
605 instrument submitted to the health maintenance organization’s
606 designated location that consists of the HCFA 1500 data set, or
607 its successor, that has all mandatory entries for a physician
608 licensed under chapter 458, chapter 459, chapter 460, chapter
609 461, or chapter 463, or psychologists licensed under chapter 490
610 or any appropriate billing instrument that has all mandatory
611 entries for any other noninstitutional provider. For
612 institutional providers, the term “claim” means a paper or
613 electronic billing instrument submitted to the health
614 maintenance organization’s designated location that consists of
615 the UB-92 data set or its successor with entries stated as
616 mandatory by the National Uniform Billing Committee.
617 (b) However, if the context so indicates, the term “claim”
618 or “pharmacy claim” means a paper or electronic billing
619 instrument submitted to a pharmacy benefit manager acting on
620 behalf of a health maintenance organization.
621 (14) Notwithstanding paragraph (3)(b), if where an
622 electronic pharmacy claim is submitted to a pharmacy benefit
623 benefits manager acting on behalf of a health maintenance
624 organization, the pharmacy benefit benefits manager must shall,
625 within 30 days after of receipt of the claim, pay the claim or
626 notify a provider or designee if a claim is denied or contested.
627 Notice of the organization’s action on the claim and payment of
628 the claim is considered to be made on the date the notice or
629 payment was mailed or electronically transferred.
630 (15) Notwithstanding paragraph (4)(a), if effective
631 November 1, 2003, where a nonelectronic pharmacy claim is
632 submitted to a pharmacy benefit benefits manager acting on
633 behalf of a health maintenance organization, the pharmacy
634 benefit benefits manager must shall provide acknowledgment of
635 receipt of the claim within 30 days after receipt of the claim
636 to the provider or provide a provider within 30 days after
637 receipt with electronic access to the status of a submitted
638 claim.
639 (16)(a) A pharmacy benefit manager may not:
640 1. Charge a pharmacist or pharmacy a fee related to the
641 payment of a pharmacy claim, including, but not limited to, a
642 fee for:
643 a. The submission of the claim;
644 b. The pharmacist’s or pharmacy’s enrollment or
645 participation in a retail pharmacy network; or
646 c. The processing or transmission of the claim; or
647 2. Retroactively deny, hold back, or reduce payment for a
648 covered claim after payment for the claim.
649 (b) The department shall have access to all financial and
650 utilization records in the possession of, and data and
651 information used by, a pharmacy benefit manager in relation to
652 the pharmacy benefit management services provided to health
653 maintenance organizations or other providers using the pharmacy
654 benefit management services in this state.
655 (c) This subsection applies to contracts entered into,
656 amended, or renewed on or after January 1, 2023.
657 Section 13. This act shall take effect upon becoming a law.
