SESSION WATCH
THE BILL ITSELF

CS/HB 697

Drug Prices and Coverage

VERSION H 697 er · BACK TO THE SUMMARY · OFFICIAL RECORD

underlined language is being added; struck language is being deleted. Line numbers are the Legislature's own — the same ones amendments cite.

2 An act relating to drug prices and coverage; amending
3 s. 626.8825, F.S.; revising the definition of the term
4 "pharmacy benefits plan or program" to exclude a plan
5 or program that exclusively serves a PACE
6 organization; requiring contracts between pharmacy
7 benefit managers and participating pharmacies to allow
8 a specified option in the administrative appeal
9 procedure; amending s. 626.8827, F.S.; providing
10 pharmacy benefit manager prohibited practices relating
11 to pharmacies and pharmacists; providing an
12 appropriation for implementation of the Ryan White
13 Part B AIDS Drug Assistance Program (ADAP) through a
14 specified date; defining the term "low income" for
15 purposes of ADAP eligibility through a specified date;
16 providing requirements for the implementation of ADAP
17 through a specified date; requiring the Department of
18 Health to submit monthly reports providing a detailed
19 accounting of ADAP to the Governor's Office of Policy
20 and Budget and the chairs of the legislative
21 appropriations committees; specifying requirements for
22 the reports; requiring the department to adopt
23 emergency rules to implement ADAP; providing that such
24 emergency rules are exempt from specified rulemaking
25 requirements and remain in effect through a specified
26 date; providing effective dates.
28 Be It Enacted by the Legislature of the State of Florida:
30 Section 1. Paragraph (u) of subsection (1) and paragraph
31 (h) of subsection (3) of section 626.8825, Florida Statutes, are
32 amended to read:
33 626.8825 Pharmacy benefit manager transparency and
34 accountability.—
35 (1) DEFINITIONS.—As used in this section, the term:
36 (u) "Pharmacy benefits plan or program" means a plan or
37 program that pays for, reimburses, covers the cost of, or
38 provides access to discounts on pharmacist services provided by
39 one or more pharmacies to covered persons who reside in, are
40 employed by, or receive pharmacist services from this state.
41 1. The term includes, but is not limited to, health
42 maintenance organizations, health insurers, self-insured
43 employer health plans, discount card programs, and government-
44 funded health plans, including the Statewide Medicaid Managed
45 Care program established pursuant to part IV of chapter 409 and
46 the state group insurance program pursuant to part I of chapter
47 110.
48 2. The term excludes such a plan or program under chapter
49 440 or a plan or program that exclusively serves a PACE
50 organization, as defined in s. 430.84(1).
51 (3) CONTRACTS BETWEEN A PHARMACY BENEFIT MANAGER AND A
52 PARTICIPATING PHARMACY.—In addition to other requirements in the
53 Florida Insurance Code, a participation contract executed,
54 amended, adjusted, or renewed on or after July 1, 2023, that
55 applies to pharmacist services on or after January 1, 2024,
56 between a pharmacy benefit manager and one or more pharmacies or
57 pharmacists, must include, in substantial form, terms that
58 ensure compliance with all of the following requirements, and
59 that, except to the extent not allowed by law, shall supersede
60 any contractual terms in the participation contract to the
61 contrary:
62 (h) The pharmacy benefit manager shall provide a
63 reasonable administrative appeal procedure to allow a pharmacy
64 or pharmacist to challenge the maximum allowable cost pricing
65 information and the reimbursement made under the maximum
66 allowable cost as defined in s. 627.64741 for a specific drug as
67 being below the acquisition cost available to the challenging
68 pharmacy or pharmacist.
69 1. The administrative appeal procedure must include a
70 telephone number and e-mail address, or a website, for the
71 purpose of submitting the administrative appeal. The appeal may
72 be submitted by the pharmacy or an agent of the pharmacy
73 directly to the pharmacy benefit manager or through a pharmacy
74 service administration organization. The administrative appeal
75 procedure must allow a pharmacy or pharmacist the option to
76 submit a consolidated administrative appeal representing
77 multiple adjudicated claims that share the same drug and day
78 supply and have a date of service occurring within the same
79 calendar month. The pharmacy or pharmacist must be given at
80 least 30 business days after a maximum allowable cost update or
81 after an adjudication for an electronic claim or reimbursement
82 for a nonelectronic claim to file the administrative appeal.
83 2. The pharmacy benefit manager must respond to the
84 administrative appeal within 30 business days after receipt of
85 the appeal.
86 3. If the appeal is upheld, the pharmacy benefit manager
87 must:
88 a. Update the maximum allowable cost pricing information
89 to at least the acquisition cost available to the pharmacy;
90 b. Permit the pharmacy or pharmacist to reverse and rebill
91 the claim in question;
92 c. Provide to the pharmacy or pharmacist the national drug
93 code on which the increase or change is based; and
94 d. Make the increase or change effective for each
95 similarly situated pharmacy or pharmacist who is subject to the
96 applicable maximum allowable cost pricing information.
97 4. If the appeal is denied, the pharmacy benefit manager
98 must provide to the pharmacy or pharmacist the national drug
99 code and the name of the national or regional pharmaceutical
100 wholesalers operating in this state which have the drug
101 currently in stock at a price below the maximum allowable cost
102 pricing information.
103 5. Every 90 days, a pharmacy benefit manager shall report
104 to the office the total number of appeals received and denied in
105 the preceding 90-day period, with an explanation or reason for
106 each denial, for each specific drug for which an appeal was
107 submitted pursuant to this paragraph.
108 Section 2. Subsections (8) and (9) are added to section
109 626.8827, Florida Statutes, to read:
110 626.8827 Pharmacy benefit manager prohibited practices.—In
111 addition to other prohibitions in this part, a pharmacy benefit
112 manager may not do any of the following:
113 (8) Prohibit or restrict a pharmacy or pharmacist from
114 declining to dispense a drug if the reimbursement rate is less
115 than the actual acquisition cost incurred or would be incurred
116 by the pharmacy or pharmacist.
117 (9) Reimburse a pharmacy or pharmacist less than it
118 reimburses an affiliated pharmacy or pharmacist, as those terms
119 are defined in s. 626.8825(1).
120 Section 3. For the 2025-2026 fiscal year, the nonrecurring
121 sum of $30,901,933 from the Grants and Donations Trust Fund is
122 appropriated to the Department of Health for implementation of
123 the Ryan White Part B AIDS Drug Assistance Program (ADAP)
124 through June 30, 2026.
125 (1) For purposes of ADAP eligibility through June 30,
126 2026, the term "low income" means an adjusted gross household
127 income at or below 400 percent of the federal poverty level.
128 (2) Through June 30, 2026, ADAP services may not be
129 provided through or by the purchase of health insurance that
130 includes coverage for HIV/AIDS medications but must be provided
131 through the distribution of medications directly to eligible
132 individuals. The HIV/AIDS medications directly dispensed under
133 ADAP must include all medications listed on the Florida AIDS
134 Drug Assistance Program (ADAP) Formulary as that formulary
135 existed on March 1, 2026. The Department of Health shall
136 distribute such medications to low income individuals who have
137 met the department's eligibility requirements. The department
138 shall ensure the availability of a clinically appropriate
139 medication for individuals with a creatinine clearance of less
140 than 60 milliliters per minute and may, as necessary to
141 implement this section within appropriated funds, provide such
142 medications only to those individuals.
143 (3) The Florida AIDS Drug Assistance Program (ADAP) Self-
144 Insured Formulary as that formulary existed on March 1, 2026,
145 shall remain in effect through at least June 30, 2026.
146 (4) Beginning April 1, 2026, the Department of Health
147 shall submit monthly reports providing a detailed accounting of
148 ADAP to the Governor's Office of Policy and Budget, the chair of
149 the Senate Committee on Appropriations, and the chair of the
150 House of Representatives Budget Committee.
151 (a) The reports must include, at a minimum, all of the
152 following:
153 1. All state and federal revenues and expenditures;
154 2. All manufacturer rebates and other pharmaceutical
155 offsets received or accrued;
156 3. The total number of individuals participating in the
157 program;
158 4. Participant counts by county of residence or
159 administering organization, as applicable;
160 5. Participants' insurance statuses;
161 6. The number and type of prescriptions filled, including
162 utilization by drug class; and
163 7. Any other information necessary to provide transparency
164 with regard to program operations, utilization trends, cost
165 drivers, and fiscal sustainability.
166 (b) The department shall also include in its reports
167 month-over-month and year-to-date trend analyses and identify
168 any projected funding shortfalls, enrollment pressures, or
169 operational risks anticipated within the current fiscal year.
170 (c) Reports must be submitted in a consistent format to
171 allow comparison across reporting periods.
172 (5) The Department of Health shall adopt emergency rules
173 to implement ADAP in accordance with this section. Emergency
174 rules adopted under this section are exempt from s.
175 120.54(4)(c), Florida Statutes, and shall remain in effect
176 through June 30, 2026.
178 This section shall take effect upon this act becoming a law.
179 Section 4. Except as otherwise expressly provided in this
180 act and except for this section, which shall take effect upon
181 this act becoming a law, this act shall take effect July 1,
182 2026.