Bill Text: FL S1142 | 2016 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

---

Bill Title: Treatments for Stable Patients

Spectrum: Bipartisan Bill

Status: (Failed) 2016-03-11 - Died in Appropriations [S1142 Detail]

Download: Florida-2016-S1142-Introduced.html

---

       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.