Christine Jordan Sexton
Pharmacy benefit managers (PBMs) that don’t register with the state can face a $10,000 fine under a bill moving its way through the House.
The House Health & Human Services Committee Tuesday unanimously approved HB 357. The bill now is available for consideration by the full House. According to House documents, 96 lobbyists have registered to lobby on the bill.
Its Senate counterpart (SB 1476) by Sen. Tom Wright has not been heard by any Senate panel. While the House bill drew nearly 100 registered lobbyists, there are just 16 lobbyists registered on the Senate bill, documents show.
The House bill passed unanimously and was supported by a variety of lobbyists from hospitals to physicians to small independent pharmacists, all of which waived their testimony in support of the bill.
Rep. Jackie Toledo made brief remarks before members of the House health care panel voted on the bill.
“As prescription drug costs continue to rise, we will work to lower those costs,” Toledo said. “And one of the ways is through this bill, so I ask for your favorable support, and co-sponsorship,” she said.
PBMs are responsible for managing the pharmacy benefits of about 270 million Americans. The staff analysis of the bill shows there are 66 PBMs registered in the state. Express Scripts, CVS Caremark and OptumRx have a combined market share of more than 89%.
Toledo’s bill builds off the Florida Pharmacy Act, initially passed in 2014 and amended in 2018.
The 2018 bill, signed into law by Gov. Rick Scott, required PBMs to register with the Office of Insurance Regulation by Jan. 1, 2019. That law did not provide for enforcement of the registration requirement.
The initial 2014 law established the rights that pharmacists are entitled to while being audited. Pharmacists are entitled under existing law to have seven days’ advance notice before any initial onsite audit can be conducted. Florida law precludes PBMs and insurers from conducting audits on claims that had been submitted or settled more than 24 months from the audit date.
Also, pharmacists under current law are allowed to be reimbursed for claims that were retroactively denied for a clerical, scrivener’s, typographical, or computer error if the patient received the correct medication, dose, and instructions for administration. There is an exception in instances of fraud or for pharmacists who make repeated errors.
But those rights are enforced by the Department of Health and the Florida Board of Pharmacy which have oversight of pharmacist but not PBMs or insurance companies or HMOs.
Toledo’s bill transfers the 2014 audit protections from state health regulators to the Florida Office of Insurance Regulation, giving the office the authority sanction PBMs that violate the law. The bill makes clear that a health insurer or HMO responsible for violations of the pharmacy audit.
The bill also amends the law to allow the findings of a PBM audit to be appealed Statewide Provider and Health Plan Claim Dispute Resolution Program.
