Pharmacy Benefit Manager Examinations
Understanding Florida's PBM Examinations
What is a Pharmacy Benefit Manager (PBM)?
PBMs act as middle-men between health insurance plans, pharmacies, and drug manufacturers. They manage prescription drug benefits, negotiate drug prices, and determine which medications are covered.
Why These Reviews Matter
Following the passage of Florida's Prescription Drug Reform Act (SB 1550) signed by Governor DeSantis, oversight of PBMs has significantly increased. The law ensures that PBMs operating in Florida remain transparent, accountable, and fully compliant with state regulations.
To enforce this, the Florida Office of Insurance Regulation (OIR) conducts biennial (every two years) examinations of every registered PBM in the state.
How the Examination Process Works
The Review Cycle: The first official two-year review cycle began on January 1, 2025.
Key Focus Areas: Examiners look closely at compliance with Florida Statutes (specifically sections 626.8825 and 626.8827) to ensure PBMs are following state laws and fair business practices.
A critical part of the examination process involves reviewing contracts between PBMs and pharmacy benefit plans or programs and contracts between PBMs and participating pharmacies to ensure the contracts contain statutorily required language.
Privacy and Data Security
OIR takes data security seriously, particularly in light of recent industry data breaches:
- Unrestricted Access: PBMs are required by law to provide unredacted, unaltered data and grant examiners full access to necessary records.
- Protecting Patient Privacy: PBMs sometimes raise concerns about sharing Protected Health Information (PHI). However, federal guidelines (from the U.S. Department of Health and Human Services) explicitly permit sharing PHI with state insurance regulators for oversight activities, when necessary
- Strict Safeguards: Contracted examiners are legally required to maintain rigorous administrative, physical, and technical safeguards that fully comply with HIPAA rules and Florida privacy laws.
PBM Examinations Since 2025
| PBM | Penalty |
| DST Pharmacy Solutions Inc. | No Exceptions Noted; No Fines Administered |
| Carelon | $20,000 |
| Fairos Rx | No Exceptions Noted; No Fines Administered |
| Benecard Services | $60,000 |
| Capital RX Inc. | $1,590,000 |
| Drexi Inc. | $355,000 |
| Employee Health Insurance Management, Inc. | $2,415,000 |
| MC-21 Healthcare, LLC | $310,000 |
| PERFORMRX, LLC | $335,000 |
| Prime Therapeutics Management, LLC | $20,000 |
| Prime Theapeutics, LLC | $5,000 |
| ProAct Inc. | $1,845,000 |
| Right Rx FL, LLC | $2,115,000 |
| Scrip World, LLC | $2,230,000 |
| Slate Rx LLC | $1,360,000 |
| TRHC TPA | No Exceptions Noted; No Fines Administered |
The
OIR has finalized examination reports for the above mentioned PBMs. In addition to
any other enforcement authority available to the office, the OIR shall impose
an administrative fine of $5,000 for each violation of Section 626.8825 or
626.8827, Florida, Statues. Each instance of a violation of such sections by a
pharmacy benefit manager against each individual pharmacy or prescription
benefits plan or program constitutes a separate violation. Notwithstanding
any other provision of the law, there is no limitation on aggregate fines
issued pursuant to this section. The proceeds from any administrative fine
shall be deposited into the General Revenue Fund. § 626.8828(6), F.S.