The Prescription Drug Reform Act (SB 1550), signed by Governor DeSantis in May 2023, institutes new regulatory requirements for all Pharmacy Benefit Managers (PBMs), including a requirement to become fully regulated as Insurance Administrators.
A pharmacy benefit manager, defined in section 626.88, Florida Statutes (F.S.), means a person or an entity doing business in this state which contracts to administer prescription drug benefits on behalf of a pharmacy benefits plan or program as defined in section 626.8825, F.S. The term includes, but is not limited to, a person or an entity that performs one or more of the following services on behalf of such plan or program:
This page provides information and resources on statutory requirements for PBMs.
Complaints on PBM issues regarding Florida Medicaid providers should be submitted to the Agency for Health Care Administration (AHCA). More information is available on AHCA's website here.
Beginning on January 1, 2024, PBMs operating in Florida must continue to be registered with the OIR, using the form linked below (section 624.490, F.S.), and hold a valid certificate of authority (COA) as an administrator (sections 626.88 and 626.8805, F.S.). Additionally, the Prescription Drug Reform Act requires that PBMs submit the following documentation to OIR:
Upon receipt and review of a complete application by a PBM that meets the requirements of Florida Law, the OIR will issue a COA.
Any PBM operating in Florida without a valid COA beginning on January 1, 2024, will be subject to a fine of $10,000 per violation per day.
The application form is available here.
The PBM’s financial condition (subsection 626.89(1), F.S.) and the PBM’s audited annual financial statements (subsection 626.89(2), F.S.). These should be submitted electronically within three months after the end of the administrator’s fiscal year, through http://www.floir.com/iportal. See form OIR-A3-975 to submit financial information.
A report of the total number of appeals and denials by pharmacies or pharmacists of the PBM’s decisions regarding a drug’s maximum allowable cost and reimbursement (section 626.8825, F.S.) is required to be filed with the OIR every 90 days.
PBMs are also directed to notify any pharmacy benefits plans or programs they are contracted with of the requirement (subsection 626.8825(2)(h)2., F.S.) to annually submit a statement of attestation of compliance with the requirements of subsection 626.8825(2), F.S., governing contracts between the PBM and the pharmacy benefits plans or programs. This requirement applies to all pharmacy benefits plans or programs as defined in subsection 626.8825(1)(u), F.S.
A sample attestation form is available here.
The attestations may be submitted to: PBMreporting@floir.com. If the plan or program is directed by a licensed insurer or HMO, the attestation may be submitted electronically as a periodic filing to http://www.floir.com/iportal.
All contractual arrangements executed, amended, adjusted, or renewed on or after July 1, 2023, which are applicable to pharmacy benefits covered on or after January 1, 2024, between a PBM and a Pharmacy Benefits Plan or Program must include, in substantial form, standard terms, except to the extent not allowed by law, shall supersede any contractual terms to the contrary.
Participation contracts between the PBM and participating pharmacy executed, amended, adjusted, or renewed on or after July 1, 2023, which are applicable to pharmacy services on or after January 1, 2024, between a PBM and one or more pharmacies or pharmacists must include, in substantial form, standard terms, except to the extent not allowed by law, shall supersede any contractual terms to the contrary.
A complete listing of contract terms can be found in section 626.8825(2), F.S.
The Prescription Drug Reform Act includes additional prohibitions against PBM practices, including: restricting or penalizing a pharmacy or pharmacist from disclosing relevant information to a patient, government officials, or law enforcement; communicating at the point-of-sale, or otherwise requiring, a cost-sharing obligation for a covered person that exceeds the lesser of the applicable amount in the covered person’s plan or the usual and customary price.
Additionally, the bill clarifies that Florida’s prohibition against “fail twice” step therapy protocols apply to both plans and PBMs.
The Act also provides additional protections against PBMs exerting retaliatory action against pharmacists or pharmacies that provide information to the OIR pursuant to a compliant or a query regarding compliance with this act.