Florida House Introduces International Reference Pricing and PBM Legislation

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On December 9, the Speaker of the Florida House of Representatives legislation, known as the Prescription Reduction Incentives and Competition Enhancement (PRICE) Act () that would limit reimbursement for prescription drugs by certain payers in the state to levels set based on drug prices in other countries, as well as impose new regulatory requirements on PBMs. The bill represents the most prominent effort by a state legislature to consider potentially limiting prescription drug prices based on international reference prices following the Trump Administration’s “Most Favored Nation” efforts this year to bring prices by major manufacturers and reimbursement levels in Medicaid closer to prices paid by other nations.

The Florida bill would prohibit state-regulated insurers (including individual insurance, state-regulated group insurance, and state employee plans), effective January 1, 2027, from reimbursing for a prescription drug at a level higher than a reference price published by the state based on international prices. The limit would also apply to the state’s Medicaid program to the extent that the reference price is lower than the net price the state receives after supplemental Medicaid rebates and would also prevent pharmacies from dispensing a drug to cash-pay patients at a higher level than the reference price (although this does not limit dispensing fees).

The reference price for a given drug would be determined by the state based on prices from other high-income countries (countries with at least 60 percent of the U.S. GDP per capita). However, the bill excludes from consideration prices from “countries with single-payer health systems,” defined to include “whole-market government price setting,” and directs the state to tier prices by a source country’s “health care system market orientation.” The state is directed to establish the reference price as the lowest GDP-adjusted price of the basket of permissible foreign market prices. Starting October 1, 2026, all pharmaceutical manufacturers holding permits with the state of Florida (including nonresident manufacturer permits) would be required to report international pricing to the state for the calculation of reference prices, and reference prices would be updated annually.

The bill does not limit reference prices to particular prescription drugs, suggesting all prescription drugs could be covered, but directs the state to “prioritize drugs that have little or no competition in the domestic market or have domestic prices that are the greatest differences between the domestic price and the reference price, including, but not limited to brand name and single-source drugs.”

Insurers would be required to report to the state the savings they generate from reimbursements based on the reference prices and pass along the savings generated either in premiums or lower cost-sharing.

Beyond the reference pricing provisions, the bill would also pursue various PBM and coverage reforms:

• Prohibiting PBMs from requiring pharmacies to dispense drugs if reimbursement is below acquisition cost;
• Prohibiting PBMs from reimbursing unaffiliated pharmacies less than affiliated pharmacies;
• Prohibiting PBMs from requiring patients to use a drug from a PBM-“affiliated” manufacturer when a generic or interchangeable biosimilar is available;
• Requiring that PBMs allow pharmacies to appeal multiple claims at once; and
• Prohibiting insurers from removing a drug from a formulary or moving it to a lower tier of coverage in the middle of a plan year if a manufacturer has agreed to a single acquisition price lasting the full year.

The announcement of the PRICE Act was also accompanied by the introduction of comprehensive legislation focused on health care provider and hospital regulation, the Big Beautiful Healthcare Frontier Act (), which would expand independent practice or scope of practice for various non-physician providers and remove certificate of need requirements for certain facilities, while also requiring new notifications by providers when a patient is being referred out of network and requiring insurers to count services provided at non-preferred providers toward a patient’s deductible if the cost was no higher than the network rate.

For more on these federal efforts, Manatt on Health subscribers can see the October 13 of Insights this Week.

This provision does not apply to Medicaid managed care plans, in cases where a drug has been withdrawn or had FDA safety statements, and does not affect the ability to make pharmacy-level generic or biologic substitutions.

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