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Florida's 2020 Legislative Session Convenes January 14th

Looking ahead to the upcoming legislative session, we've highlighted some of the most important bills that would affect rheumatology patients and providers in the state of Florida. We encourage all Floridians to contact their legislators, urging them to support the following proposed pieces of legislation.

HB 373: Filed in October, 2019 by Rep. Massullo, this bill addresses the problems caused by Florida's current step therapy protocols. Many of Florida's health insurers are utilizing step therapy policies requiring patients to try and fail one or more formulary covered medications before providing coverage for the originally prescribed non-formulary or non-preferred medication. Some patients are required by their health plans to try up to 5 different medications with durations lasting up to 130 days per medication. This has led to unnecessary adverse health effects for patients, the sacrificing of valuable treatment time, and significant increases in out-of-pocket costs.

What the Bill Does:

  • Creates a Clear and Convenient Exceptions Process: HB 373 allows the prescriber to override the step therapy protocol for a patient when the required drug will likely cause a significant barrier to adherence or the insured's plan of care, be ineffective, cause an adverse reaction, physical or mental harm, worsen a comorbid condition, or decrease ability to achieve or maintain functional ability. It also allows for overrides when the patient has already tried and failed the required drug, or a drug in the same pharmacologic class or with the same mechanism of action, or when the patient is already stable on a drug selected by their health care provider.
  • Creates Clear and Transparent Timelines for Issuing a Determination for a Step Therapy Protocol Exception Request: For non-urgent situations, a determination must be issued within two business days of the time of the request. For urgent situations, the time allotted is 24 hours. Failure to abide by the allotted time frames will result in approval of the exception request.
  • Prevents a Health Plan from Retroactively Denying Prior Authorizations: HB 373 prevents health plans from going back and retroactively denying prior authorizations or services rendered during the perioperative period pursuant to a prior authorization that was already approved.

SB 696 and its Companion Bill, HB 561: SB 696, filed in late October, 2019, and HB 561, filed in early November, 2019, work to protect patients from switches of their coverage for non-medical reasons. Currently, families in Florida can lose coverage of their medications at any time. They carefully shop for a health plan that covers the benefits they need, but no laws in Florida prohibit insurers from changing coverage during the course of the plan year – when families are locked into their plan. Commercial plans are free to increase copays and out-of-pocket costs, enact further restrictions on your coverage, and even remove coverage of a prescription medication.

What the Bill Does:

  • Provides Protection from Non-Medical Switching: The bill enables the insured's physician to override a medically inappropriate formulary switch for an insured by submitting a medical necessity notice, preventing the plan from increasing out-of-pocket costs for the drug, moving the drug to a more restrictive tier, denying coverage of the drug, and limiting or reducing coverage of the drug in any other way.
  • Protects Patients from Co-Pay Surprise and Deductible Double Dipping: The bill requires co-pay assistance to apply for all payments made by or on behalf of a patient towards their deductible or other cost sharing obligation.
  • Improves Transparency and Accountability for Pharmacy Benefit Managers (PBMs): PBMs will be required to file a yearly report that includes the aggregated dollar amount of rebates, fees, price protection payments, and other payments collected from pharmaceutical manufacturers. They will also be required to report the aggregated dollar amount of rebates, fees, price protection payments, and other payments collected from pharmaceutical manufacturers which were passed to health insurers or health maintenance organizations, as well as the aggregated dollar amount of rebates, fees, price protection payments, and other payments collected from pharmaceutical manufacturers which were passed to insureds at the point of sale.

HB 961: Filed in mid-December, 2019 by Rep. Jackie Toledo, this bill works to increase pharmacy benefit manager (PBM) transparency and lower drug costs for patients. PBMs serve as middle-men between pharmacies and health insurance companies to provide real-time benefit analysis and actual costs for patients purchasing prescription medication. They are meant to make it easier for pharmacies to obtain health insurance benefit information on patients so they can get their prescriptions in a timely fashion, but their presence has morphed into a profit-driven model that favors insurance providers and large pharmacy chains over patients.

PBMs play a uniquely central role in the prescription drug market, handling everything from negotiating prices with drug manufacturers and setting patient copay amounts to determining which drugs are covered by which insurers. Using deceptive tools such as spread pricing and a rebate system, PBMs have been able to quietly influence not only the prices patients pay for their prescriptions but also which drugs are available and accessible to the public.

What the Bill Does:

  • Prohibits the PBM Practice of Spread Pricing: "Spread pricing" refers to the practice by a pharmacy benefit manager of charging or claiming from a payor an amount that is more than the amount the pharmacy benefit manager paid to the pharmacy or pharmacist who filled the prescription or who provided the pharmacy services.
  • Prohibits PBMs from Profiteering from the Rebate System: The bill prevents pharmacy benefit managers from charging drug manufacturers rebates to be included on a drug formulary and keeping the rebates for their own financial gain rather than passing the savings on to health plans, health plan sponsors and providers, health insurers, and patients.

Prevents insurers from retroactively denying, holding back, or reducing reimbursement for a covered service claim after paying a claim, unless the original claim was submitted fraudulently.

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