Amendment SA4-SSA2-SB70

SB70-SSA2-SA4,92,21 (a) Whether the short-term, limited duration plan covers an individual or a family.

SB70-SSA2-SA4,92,22 (b) Rating area in the state, as established by the commissioner.

SB70-SSA2-SA4,92,25 (c) Age, except that the rate may not vary by more than 3 to 1 for adults over the age groups and the age bands shall be consistent with recommendations of the National Association of Insurance Commissioners.

SB70-SSA2-SA4,93,1 (d) Tobacco use, except that the rate may not vary by more than 1.5 to 1.

SB70-SSA2-SA4,93,3 (5) Annual and lifetime limits. A short-term, limited duration plan may not establish any of the following:

SB70-SSA2-SA4,93,5 (a) Lifetime limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan.

SB70-SSA2-SA4,93,8 (b) Limits on the dollar value of benefits for an enrollee or a dependent of an enrollee under the short-term, limited duration plan for a term of coverage or for the aggregate duration of the short-term, limited duration plan.

SB70-SSA2-SA4,101 Section 101. 632.76 (2) (ac) 3. (intro.) of the statutes is amended to read:

SB70-SSA2-SA4,93,12 632.76 (2) (ac) 3. (intro.) Except as the commissioner provides by rule under s. 632.7495 (5), all of the following apply to an individual disability insurance policy that is a short-term policy, limited duration plan subject to s. 632.7495 (4) and (5):

SB70-SSA2-SA4,102 Section 102. 632.76 (2) (ac) 3. b. of the statutes is amended to read:

SB70-SSA2-SA4,93,19 632.76 (2) (ac) 3. b. The policy shall reduce the length of time during which a may not impose any preexisting condition exclusion may be imposed by the aggregate of the insured's consecutive periods of coverage under the insurer's individual disability insurance policies that are short-term policies subject to s. 632.7495 (4) and (5). For purposes of this subd. 3. b., coverage periods are consecutive if there are no more than 63 days between the coverage periods.

SB70-SSA2-SA4,103 Section 103. 632.862 of the statutes is created to read:

SB70-SSA2-SA4,93,22 632.862 Application of prescription drug payments. (1) Definitions. In this section:

SB70-SSA2-SA4,93,23 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

SB70-SSA2-SA4,93,24 (b) “Brand name drug” means any of the following:

SB70-SSA2-SA4,94,2 1. A prescription drug that contains a brand name and that has no generic equivalent.

SB70-SSA2-SA4,94,7 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or self-insured health plan or authorization from a physician to obtain the prescription drug under the disability insurance policy or self-insured health plan.

SB70-SSA2-SA4,94,8 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

SB70-SSA2-SA4,94,9 (d) “Prescription drug” has the meaning given in s. 450.01 (20).

SB70-SSA2-SA4,94,11 (e) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

SB70-SSA2-SA4,94,17 (2) Application of discounts. A disability insurance policy that offers a prescription drug benefit or a self-insured health plan shall apply to any calculation of an out-of-pocket maximum amount and to any deductible of the disability insurance policy or self-insured health plan for an enrollee the amount that any discount provided by the manufacturer of a brand name drug reduces the cost sharing amount charged to the enrollee for that brand name drug.

SB70-SSA2-SA4,104 Section 104. 632.863 of the statutes is created to read:

SB70-SSA2-SA4,94,19 632.863 Pharmaceutical representatives. (1) Definitions. In this section:

SB70-SSA2-SA4,94,22 (a) “Health care professional” means a physician or other health care practitioner who is licensed to provide health care services or to prescribe pharmaceutical or biologic products.

SB70-SSA2-SA4,94,24 (b) “Pharmaceutical” means a medication that may legally be dispensed only with a valid prescription from a health care professional.

SB70-SSA2-SA4,95,3 (c) “Pharmaceutical representative” means an individual who markets or promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical manufacturer for compensation.

SB70-SSA2-SA4,95,10 (2) Licensure. Beginning on the first day of the 12th month beginning after the effective date of this subsection .... [LRB inserts date], no individual may act as a pharmaceutical representative in this state without being licensed by the commissioner as a pharmaceutical representative under this section. In order to obtain a license, the individual shall apply to the commissioner in the form and manner prescribed by the commissioner. The term of a license issued under this subsection is one year and is renewable.

SB70-SSA2-SA4,95,13 (3) Display of license. A pharmaceutical representative licensed under sub. (2) shall display the pharmaceutical representative's license during each visit with a health care professional.

SB70-SSA2-SA4,95,16 (4) Enforcement. (a) Any individual who violates this section shall be fined not less than $1,000 nor more than $3,000 for each offense. Each day of continued violation constitutes a separate offense.

SB70-SSA2-SA4,95,20 (b) The commissioner may suspend or revoke the license of a pharmaceutical representative who violates this section. A suspended or revoked license may not be reinstated until the pharmaceutical representative remedies all violations related to the suspension or revocation and pays all assessed penalties and fees.

SB70-SSA2-SA4,95,23 (5) Rules. The commissioner shall promulgate rules to implement this section, including rules that require pharmaceutical representatives to complete continuing educational coursework as a condition of licensure.

SB70-SSA2-SA4,105 Section 105. 632.864 of the statutes is created to read:

SB70-SSA2-SA4,96,2 632.864 Pharmacy services administrative organizations. (1) Definitions. In this section:

SB70-SSA2-SA4,96,3 (a) “Administrative service” means any of the following:

SB70-SSA2-SA4,96,4 1. Assisting with claims.

SB70-SSA2-SA4,96,5 2. Assisting with audits.

SB70-SSA2-SA4,96,6 3. Providing centralized payment.

SB70-SSA2-SA4,96,7 4. Performing certification in a specialized care program.

SB70-SSA2-SA4,96,8 5. Providing compliance support.

SB70-SSA2-SA4,96,9 6. Setting flat fees for generic drugs.

SB70-SSA2-SA4,96,10 7. Assisting with store layout.

SB70-SSA2-SA4,96,11 8. Managing inventory.

SB70-SSA2-SA4,96,12 9. Providing marketing support.

SB70-SSA2-SA4,96,13 10. Providing management and analysis of payment and drug dispensing data.

SB70-SSA2-SA4,96,14 11. Providing resources for retail cash cards.

SB70-SSA2-SA4,96,17 (b) “Independent pharmacy" means a pharmacy operating in this state that is licensed under s. 450.06 or 450.065 and is under common ownership with no more than 2 other pharmacies.

SB70-SSA2-SA4,96,18 (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

SB70-SSA2-SA4,96,20 (d) “Pharmacy services administrative organization” means an entity operating in this state that does all of the following:

SB70-SSA2-SA4,96,22 1. Contracts with an independent pharmacy to conduct business on the independent pharmacy's behalf with a 3rd-party payer.

SB70-SSA2-SA4,96,25 2. Provides at least one administrative service to an independent pharmacy and negotiates and enters into a contract with a 3rd-party payer or pharmacy benefit manager on behalf of the independent pharmacy.

SB70-SSA2-SA4,97,3 (e) “Third-party payer” means an entity, including a plan sponsor, health maintenance organization, or insurer, operating in this state that pays or insures health, medical, or prescription drug expenses on behalf of beneficiaries.

SB70-SSA2-SA4,97,10 (2) Licensure. (a) Beginning on the first day of the 12th month beginning after the effective date of this paragraph .... [LRB inserts date], no person may operate as a pharmacy services administrative organization in this state without being licensed by the commissioner as a pharmacy services administrative organization under this section. In order to obtain a license, the person shall apply to the commissioner in the form and manner prescribed by the commissioner. The application shall include all of the following:

SB70-SSA2-SA4,97,12 1. The name, address, telephone number, and federal employer identification number of the applicant.

SB70-SSA2-SA4,97,14 2. The name, business address, and telephone number of a contact person for the applicant.

SB70-SSA2-SA4,97,15 3. The fee under s. 601.31 (1) (nw).

SB70-SSA2-SA4,97,16 4. Evidence of financial responsibility of at least $1,000,000.

SB70-SSA2-SA4,97,17 5. Any other information required by the commissioner.

SB70-SSA2-SA4,97,19 (b) The term of a license issued under par. (a) shall be 2 years from the date of issuance.

SB70-SSA2-SA4,97,23 (3) Disclosure to the commissioner. (a) A pharmacy services administrative organization licensed under sub. (2) shall disclose to the commissioner the extent of any ownership or control of the pharmacy services administrative organization by an entity that does any of the following:

SB70-SSA2-SA4,97,24 1. Provides pharmacy services.

SB70-SSA2-SA4,97,25 2. Provides prescription drug or device services.

SB70-SSA2-SA4,98,2 3. Manufactures, sells, or distributes prescription drugs, biologicals, or medical devices.

SB70-SSA2-SA4,98,5 (b) A pharmacy services administrative organization licensed under sub. (2) shall notify the commissioner in writing within 5 days of any material change in its ownership or control relating to an entity described in par. (a).

SB70-SSA2-SA4,98,6 (4) Rules. The commissioner may promulgate rules to implement this section.

SB70-SSA2-SA4,106 Section 106. 632.868 of the statutes is created to read:

SB70-SSA2-SA4,98,8 632.868 Insulin safety net programs. (1) Definitions. In this section:

SB70-SSA2-SA4,98,10 (a) “Manufacturer" means a person engaged in the manufacturing of insulin that is self-administered on an outpatient basis.

SB70-SSA2-SA4,98,11 (b) “Navigator" has the meaning given in s. 628.90 (3).

SB70-SSA2-SA4,98,13 (c) “Patient assistance program” means a program established by a manufacturer under sub. (3) (a).

SB70-SSA2-SA4,98,14 (d) “Pharmacy" means an entity licensed under s. 450.06 or 450.065.

SB70-SSA2-SA4,98,17 (e) “Urgent need of insulin" means having less than a 7-day supply of insulin readily available for use and needing insulin in order to avoid the likelihood of suffering a significant health consequence.

SB70-SSA2-SA4,98,19 (f) “Urgent need safety net program” means a program established by a manufacturer under sub. (2) (a).

SB70-SSA2-SA4,98,23 (2) Urgent need safety net program. (a) Establishment of program. No later than July 1, 2024, each manufacturer shall establish an urgent need safety net program to make insulin available in accordance with this subsection to individuals who meet the eligibility requirements under par. (b).

SB70-SSA2-SA4,98,25 (b) Eligible individual. An individual shall be eligible to receive insulin under an urgent need safety net program if all of the following conditions are met:

SB70-SSA2-SA4,99,1 1. The individual is in urgent need of insulin.

SB70-SSA2-SA4,99,2 2. The individual is a resident of this state.

SB70-SSA2-SA4,99,3 3. The individual is not receiving public assistance under ch. 49.

SB70-SSA2-SA4,99,8 4. The individual is not enrolled in prescription drug coverage through an individual or group health plan that limits the total cost sharing amount, including copayments, deductibles, and coinsurance, that an enrollee is required to pay for a 30-day supply of insulin to no more than $75, regardless of the type or amount of insulin prescribed.

SB70-SSA2-SA4,99,10 5. The individual has not received insulin under an urgent need safety net program within the previous 12 months, except as allowed under par. (d).

SB70-SSA2-SA4,99,14 (c) Provision of insulin under an urgent need safety net program. 1. In order to receive insulin under an urgent need safety net program, an individual who meets the eligibility requirements under par. (b) shall provide a pharmacy with all of the following:

SB70-SSA2-SA4,99,18 a. A completed application, on a form prescribed by the commissioner that shall include an attestation by the individual, or the individual's parent or legal guardian if the individual is under the age of 18, that the individual meets all of the eligibility requirements under par. (b).

SB70-SSA2-SA4,99,19 b. A valid insulin prescription.

SB70-SSA2-SA4,99,22 c. A valid Wisconsin driver's license or state identification card. If the individual is under the age of 18, the individual's parent or legal guardian shall meet this requirement.

SB70-SSA2-SA4,99,25 2. Upon receipt of the information described in subd. 1. a. to c., the pharmacist shall dispense a 30-day supply of the prescribed insulin to the individual. The pharmacy shall also provide the individual with the information sheet described in sub. (8) (b) 2. and the list of navigators described in sub. (8) (c). The pharmacy may collect a copayment, not to exceed $35, from the individual to cover the pharmacy's costs of processing and dispensing the insulin. The pharmacy shall notify the health care practitioner who issued the prescription no later than 72 hours after the insulin is dispensed.

SB70-SSA2-SA4,100,13 3. A pharmacy that dispenses insulin under subd. 2. may submit to the manufacturer, or the manufacturer's vendor, a claim for payment that is in accordance with the national council for prescription drug programs' standards for electronic claims processing, except that no claim may be submitted if the manufacturer agrees to send the pharmacy a replacement of the same insulin in the amount dispensed. If the pharmacy submits an electronic claim, the manufacturer or vendor shall reimburse the pharmacy in an amount that covers the pharmacy's acquisition cost.

SB70-SSA2-SA4,100,15 4. A pharmacy that dispenses insulin under subd. 2. shall retain a copy of the application form described in subd. 1. a.

SB70-SSA2-SA4,100,22 (d) Eligibility of certain individuals. An individual who has applied for public assistance under ch. 49 but for whom a determination of eligibility has not been made or whose coverage has not become effective or an individual who has an appeal pending under sub. (3) (c) 4. may access insulin under this subsection if the individual is in urgent need of insulin. To access a 30-day supply of insulin, the individual shall attest to the pharmacy that the individual is described in this paragraph and comply with par. (c) 1.

SB70-SSA2-SA4,101,2 (3) Patient assistance program. (a) Establishment of program. No later than July 1, 2024, each manufacturer shall establish a patient assistance program to make insulin available in accordance with this subsection to individuals who meet the eligibility requirements under par. (b). Under the patient assistance program, the manufacturer shall do all of the following:

SB70-SSA2-SA4,101,5 1. Provide the commissioner with information regarding the patient assistance program, including contact information for individuals to call for assistance in accessing the patient assistance program.