Written by a parent, not a doctor. Nothing here is medical advice.

Childhood Cancer Lantern
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Florida program

Keeping a medicine or doctor after a plan change

Florida protects some ongoing drug treatment and HMO care when insurance or a doctor’s contract changes.

What it is

Florida protects some ongoing drug treatment and HMO care when insurance or a doctor’s contract changes.

A new plan may ask your child to try a cheaper drug first. Florida’s step-therapy exception can help when the earlier plan approved and paid for the drug within 90 days. A separate HMO rule can protect active treatment after a doctor leaves the network.

Eligibility rules
  • These rules reach plans an insurer sells in Florida. A plan the employer funds itself usually follows federal rules instead; one question to HR settles which you have.
  • The HMO continuity protection does not apply when the doctor’s contract ended for cause. Public self-funded plan applicability needs a plan-specific check.
What you get
  • A step-therapy exception when the earlier plan’s approval and payment meet the 90-day test.
  • Up to six months of continued active treatment after a qualifying HMO doctor-contract change.
What the help covers
  • The 90 days are a look-back for the earlier plan’s payment, not a promise of a decision within 90 days.
  • The six-month rule concerns HMOs. A PPO’s federal continuity right is a separate 90-day protection under its qualifying conditions.
If you decide to apply
  1. Ask the clinic’s insurance navigator to request the applicable exception or continued care.
  2. Gather the earlier plan’s approval, payment explanation and the doctor’s treatment records.
  3. Ask the plan for the request deadline and response timeframe in writing.

Your clinic’s insurance navigator and the health plan · Official page ↗

What happens next
  • The navigator can help the clinic identify the actual deadline and document urgency. Florida’s prior-authorization form law sets no single deadline for every request. The step-therapy law requires a published process and a decision within a reasonable time. Medicaid and private-plan clocks are different.
Good to know

Florida has no general state prior-approval clock under these provisions. Federal and plan-specific deadlines remain separate.

Official sources
Ask your social worker

“Would the earlier plan’s drug payment or our child’s ongoing treatment give us an exception? What limits apply, and could the clinic help send the right request?”

Why I’m asking: I want a plan or network change to avoid disrupting treatment that is already working.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask the clinic for the plan's written deadlines, keep the old plan's approval and payment records, and put any continuity request in writing.

Your social worker

The social worker connects you with the clinic's insurance navigator, who tracks each request.

The care team

Sends complete requests, marks urgent ones, and documents the prior approval for a step-therapy exemption.

Who decides
The plan's reviewers, on the plan's own timeframes; Florida regulators enforce the step-therapy and continuity rules for insured plans.
Ask the care team
“Florida has no prior-approval deadline, so what deadlines did our plan give in writing for this request? If we change plans, can you send the old plan's approval and payment record within 90 days?”

How to apply

First step: Ask the clinic's insurance navigator to get the plan's urgent and standard prior-approval deadlines in writing and to mark urgent requests. On a plan change, send the old plan's approval and payment record at once.

  1. Ask the plan, in writing, for its urgent and standard prior-approval deadlines; Florida sets none.
  2. On a plan change, send the old plan's approval and payment record within 90 days to block step therapy.
  3. If the oncology group leaves an HMO network, ask the HMO in writing for continuity through active treatment (up to 6 months).

Where it starts: The clinic's insurance navigator requests the exemption with the prior plan's payment documentation, or the continuity election when a provider leaves

What to gather

  • The plan's written prior-approval deadlines
  • The previous plan's approval and payment records (explanation of benefits)
  • For an HMO: the notice that the provider's contract is ending

How long: Prior approval: the plan's own timeframe. Step-therapy exemption: 'a reasonable time' under the law. HMO continuity: through active treatment, up to 6 months.

What a yes looks like

A written approval, an exemption granted on the prior plan's documentation, or an HMO letter confirming continuity through treatment.

What a no looks like, and the next move

Appeal by the letter's date and use the outside-review item. For an insured plan, Florida's Department of Financial Services consumer helpline takes complaints; a self-funded plan follows its own rules.

Watch out

  • No Florida prior-approval deadline and no 'gold card' for doctors: the two reform bills (SB 1130 and HB 1015) died on March 13, 2026. The plan's own timeframes apply; get them in writing.
  • The step-therapy exemption needs the previous plan's own paperwork showing it paid for the drug within the last 90 days. Save every explanation of benefits before a plan change.
  • The 6-month continuity rule is an HMO rule and does not apply when the doctor's contract ended for cause. A PPO has only the federal 90-day continuity right.
  • Florida’s state-group fertility benefit is separate from district-teacher coverage. The state Aetna appeal document has conflicting external-review deadline wording; request the applicable deadline in writing and act promptly.

If they say no, quote this: Step-therapy exemption: Fla. Stat. §627.42393 (insurers), §641.31(46) (HMOs). HMO continuity after a provider leaves: §641.51(8).

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

Step-therapy exemption when the previous plan approved and paid for the drug within 90 days; up to 6 months of continued treatment when an HMO's contract with your child's doctor ends. No Florida prior-approval deadline.

  • $90 — Step-therapy exemption: prior plan paid for the drug within the preceding
  • $6 — HMO continuity of active treatment after a provider contract ends (not for cause), at most

Legal protection: No step-therapy protocol for a drug a previous plan approved and paid for within the preceding 90 days, with the plan's documentation (§627.42393(2); §641.31(46)) · Step-therapy exemption requests decided "within a reasonable time" (§627.42393(3)(a)2) · HMO: continued coverage and care through completion of active treatment when the treating provider's contract ends other than for cause, up to 6 months (§641.51(8))

What it costs the family: None.

The eligibility facts, as published

Plans bound
major medical individual or group insurance policies (§627.42393) and HMO individual or group contracts (§641.31(46), §641.51(8))
Self funded
ERISA plans excluded from Florida self-insurance regulation (§627.651(4)); public self-funded plan applicability not established
Prior authorization clock
none in Florida law; SB 1130 and HB 1015 (2026) died 2026-03-13
Step therapy lookback days
90
Hmo continuity max months
6

Expect friction on: Fully insured versus self-funded · HMO versus PPO for continuity

The trap: Assuming a '72-hour urgent' state deadline exists. In Florida the plan's own timeframes govern prior approval; the step-therapy law only says an exemption request must be decided within a reasonable time.

Where I read this

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