Andrew Powell
New legislation has been proposed to enhance transparency and ensure patients maintain access to essential medications through their insurance providers.
Tampa Republican Rep. Karen Gonzalez Pittman filed the bill (HB 899), which aims to protect health insurance policy holders from unexpected increases in drug costs during the policy year, and to implement tighter safeguards.
The bill would create and amend several Florida statutes, including changing policies to require insurers to notify current and prospective health insurance policy holders, as well as their treating physicians, of any changes to the prescription drug pricing formula at least 60 days before the effective date.
Patient advocacy groups have been calling for similar transparency reforms for some time. In 2022, the Infusion Access Foundation called on former Florida Attorney General Ashley Moody to provide more oversight for the federal 340B Drug Pricing Program. The foundation wanted to ensure that low-income and uninsured Americans, particularly those with chronic illnesses, were being provided with effective access to affordable drugs and treatments.
If passed, insurers would be prohibited from modifying coverage during the policy year, including increasing any out-of-pocket costs, moving the covered drug to a more restrictive drug tier, denying coverage if it was previously approved, or limiting or reducing coverage of the drug in any other way.
Insurers would be required to maintain records of drug formula changes and submit annual reports to the Office of Insurance Regulation (OIR). The reports would include details such as removed drugs, policy holders impacted by the change, and the increases in costs for policy holders. OIR would be required to compile the data, make the information publicly available, and summarize findings in a report that would then go to the Governor and the Legislature.
Florida statutes would further be created to implement cost-sharing requirements for health insurers, defined in the bill as a dollar limit, a deductible, a copayment, coinsurance, or any other out-of-pocket expense for policy holders. Payments made by or on behalf of the insured for prescription drugs would be applied to cost-sharing requirements if certain conditions are met. That would apply to both individual and group health insurers and their pharmacy benefit managers.
Health maintenance organizations would have similar rules applied, including the requirement to notify policy holders and treating physicians of any formula changes to medications, as well as maintaining records and submitting required annual reports.
Treating physicians would be able to submit a notice of medical necessity, to ensure coverage continues for prescribed drugs despite any formula changes, and ensure patient access is safeguarded.
The bill specifies that it applies to health insurance policies, health benefit plans, and health maintenance contracts entered into or renewed on or after January 1, 2026. If passed, the bill would take effect July 1.
