Amendment SA4-SSA2-SB45

SB45-SSA2-SA4,151,11 (3) The commissioner shall specify the proportion of prior authorization requests submitted by a health care provider that have to be approved for the health care provider to qualify for an exemption from obtaining prior authorizations under sub. (2).

SB45-SSA2-SA4,151,14 (4) The commissioner may specify by rule the health care items or services that may be subject to the exemption from obtaining prior authorizations under sub. (2).

SB45-SSA2-SA4,151,17 (5) The commissioner may specify how health care providers may obtain an exemption from obtaining prior authorizations under sub. (2) including by providing a process for automatic evaluation.

SB45-SSA2-SA4,151,19 (6) The commissioner may promulgate further rules necessary to implement this section.

SB45-SSA2-SA4,240 Section 240. 632.851 of the statutes is created to read:

SB45-SSA2-SA4,151,22 632.851 Reimbursement of emergency ambulance services. (1) In this section:

SB45-SSA2-SA4,151,23 (a) “Ambulance service provider” has the meaning given in s. 256.01 (3).

SB45-SSA2-SA4,152,3 (b) “Clean claim” means a claim that has no defect of impropriety, including a lack of required substantiating documentation or any particular circumstance that requires special treatment that prevents timely payment from being made on the claim.

SB45-SSA2-SA4,152,4 (c) “Emergency medical responder” has the meaning given in s. 256.01 (4p).

SB45-SSA2-SA4,152,6 (d) “Emergency medical services practitioner” has the meaning given in s. 256.01 (5).

SB45-SSA2-SA4,152,7 (e) “Firefighter” has the meaning given in s. 36.27 (3m) (a) 1m.

SB45-SSA2-SA4,152,8 (f) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp).

SB45-SSA2-SA4,152,9 (g) “Law enforcement officer” has the meaning given in s. 165.85 (2) (c).

SB45-SSA2-SA4,152,10 (h) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

SB45-SSA2-SA4,152,16 (2) (a) A disability insurance policy or self-insured health plan shall, within 30 days after receipt of a clean claim for covered emergency ambulance services, promptly remit payment for the covered emergency ambulance services directly to the ambulance service provider. No disability insurance policy or self-insured health plan may send a payment for covered emergency ambulance services to an enrollee.

SB45-SSA2-SA4,152,21 (b) A disability insurance policy or self-insured health plan shall respond to a claim for covered emergency ambulance services that is not a clean claim by sending a written notice, within 30 days after receipt of the claim, acknowledging the date of receipt of the claim and informing the ambulance service provider of one of the following:

SB45-SSA2-SA4,152,23 1. That the disability insurance policy or self-insured health plan is declining to pay all or part of the claim, including the specific reason or reasons for the denial.

SB45-SSA2-SA4,153,2 2. That additional information is necessary to determine if all or part of the claim is payable and the specific additional information that is required.

SB45-SSA2-SA4,153,7 (3) A disability insurance policy or self-insured health plan shall remit payment for the transportation of any patient by ambulance as a medically necessary emergency ambulance service if the transportation was requested by an emergency medical services practitioner, an emergency medical responder, a firefighter, a law enforcement officer, or a health care provider.

SB45-SSA2-SA4,241 Section 241. 632.862 of the statutes is created to read:

SB45-SSA2-SA4,153,10 632.862 Application of prescription drug payments. (1) Definitions. In this section:

SB45-SSA2-SA4,153,11 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

SB45-SSA2-SA4,153,12 (b) “Brand name drug” means any of the following:

SB45-SSA2-SA4,153,14 1. A prescription drug that contains a brand name and that has no generic equivalent.

SB45-SSA2-SA4,153,19 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.

SB45-SSA2-SA4,153,20 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

SB45-SSA2-SA4,153,21 (d) “Prescription drug” has the meaning given in s. 450.01 (20).

SB45-SSA2-SA4,153,23 (e) “Self-insured health plan” means a self-insured health plan of the state or a county, city, village, town, or school district.

SB45-SSA2-SA4,154,6 (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.

SB45-SSA2-SA4,242 Section 242. 632.863 of the statutes is created to read:

SB45-SSA2-SA4,154,9 632.863 Pharmaceutical representatives. (1) Definitions. In this section:

SB45-SSA2-SA4,154,12 (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.

SB45-SSA2-SA4,154,14 (b) “Pharmaceutical” means a medication that may legally be dispensed only with a valid prescription from a health care professional.

SB45-SSA2-SA4,154,17 (c) “Pharmaceutical representative” means an individual who markets or promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical manufacturer for compensation.

SB45-SSA2-SA4,155,2 (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 subsection. In order to obtain a license under this subsection, the individual shall apply to the commissioner in the form and manner prescribed by the commissioner and shall pay the fee under s. 601.31 (1) (nv). The term of a license issued under this subsection is one year, and the license is renewable.

SB45-SSA2-SA4,155,5 (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.

SB45-SSA2-SA4,155,9 (4) Enforcement. (a) Any individual who violates this section or any rules promulgated under 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.

SB45-SSA2-SA4,155,14 (b) The commissioner may suspend or revoke the license of a pharmaceutical representative who violates this section or any rules promulgated under this section. A suspended or revoked license under this paragraph may not be reinstated until the pharmaceutical representative remedies all violations related to the suspension or revocation and pays all assessed penalties and fees.

SB45-SSA2-SA4,155,17 (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.

SB45-SSA2-SA4,243 Section 243. 632.864 of the statutes is created to read:

SB45-SSA2-SA4,155,20 632.864 Pharmacy services administrative organizations. (1) Definitions. In this section:

SB45-SSA2-SA4,155,21 (a) “Administrative service” means any of the following:

SB45-SSA2-SA4,155,22 1. Assisting with claims.

SB45-SSA2-SA4,155,23 2. Assisting with audits.

SB45-SSA2-SA4,156,1 3. Providing centralized payment.

SB45-SSA2-SA4,156,2 4. Performing certification in a specialized care program.

SB45-SSA2-SA4,156,3 5. Providing compliance support.

SB45-SSA2-SA4,156,4 6. Setting flat fees for generic drugs.

SB45-SSA2-SA4,156,5 7. Assisting with store layout.

SB45-SSA2-SA4,156,6 8. Managing inventory.

SB45-SSA2-SA4,156,7 9. Providing marketing support.

SB45-SSA2-SA4,156,9 10. Providing management and analysis of payment and drug dispensing data.

SB45-SSA2-SA4,156,10 11. Providing resources for retail cash cards.

SB45-SSA2-SA4,156,13 (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.

SB45-SSA2-SA4,156,14 (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

SB45-SSA2-SA4,156,16 (d) “Pharmacy services administrative organization” means an entity operating in this state that does all of the following:

SB45-SSA2-SA4,156,18 1. Contracts with an independent pharmacy to conduct business with a 3rd- party payer on the independent pharmacy’s behalf.

SB45-SSA2-SA4,156,21 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.

SB45-SSA2-SA4,157,2 (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.

SB45-SSA2-SA4,157,9 (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 without being licensed by the commissioner as a pharmacy services administrative organization under this subsection. In order to obtain a license under this paragraph, the person shall apply to the commissioner in the form and manner prescribed by the commissioner. The application for licensure under this paragraph shall include all of the following:

SB45-SSA2-SA4,157,11 1. The name, address, telephone number, and federal employer identification number of the applicant.

SB45-SSA2-SA4,157,13 2. The name, business address, and telephone number of a contact person for the applicant.

SB45-SSA2-SA4,157,14 3. The fee under s. 601.31 (1) (nw).

SB45-SSA2-SA4,157,15 4. Evidence of financial responsibility of at least $1,000,000.

SB45-SSA2-SA4,157,16 5. Any other information required by the commissioner.

SB45-SSA2-SA4,157,18 (b) The term of a license issued under par. (a) shall be 2 years from the date of issuance.

SB45-SSA2-SA4,157,23 (c) A license issued under par. (a) may be renewed. Renewal applications shall be submitted to the commissioner on a form provided by the commissioner and shall include all the items described in par. (a) 1. to 5. A renewal application under this paragraph may not be submitted more than 90 days prior to the end of the term of the license being renewed.

SB45-SSA2-SA4,158,4 (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:

SB45-SSA2-SA4,158,5 1. Provides pharmacy services.

SB45-SSA2-SA4,158,6 2. Provides prescription drug or device services.

SB45-SSA2-SA4,158,8 3. Manufactures, sells, or distributes prescription drugs, biologicals, or medical devices.

SB45-SSA2-SA4,158,11 (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).

SB45-SSA2-SA4,158,13 (4) Rules. The commissioner may promulgate rules to implement this section.

SB45-SSA2-SA4,244 Section 244. 632.865 (2m) of the statutes is created to read:

SB45-SSA2-SA4,158,18 632.865 (2m) Fiduciary duty and disclosures to health benefit plan sponsors. (a) A pharmacy benefit manager owes a fiduciary duty to the health benefit plan sponsor to act according to the health benefit plan sponsor’s instructions and in the best interests of the health benefit plan sponsor.

SB45-SSA2-SA4,158,22 (b) A pharmacy benefit manager shall annually provide, no later than the date and using the method prescribed by the commissioner by rule, the health benefit plan sponsor all of the following information from the previous calendar year:

SB45-SSA2-SA4,159,2 1. The indirect profit received by the pharmacy benefit manager from owning any interest in a pharmacy or service provider.

SB45-SSA2-SA4,159,4 2. Any payment made by the pharmacy benefit manager to a consultant or broker who works on behalf of the health benefit plan sponsor.

SB45-SSA2-SA4,159,8 3. From the amounts received from all drug manufacturers, the amounts retained by the pharmacy benefit manager, and not passed through to the health benefit plan sponsor, that are related to the health benefit plan sponsor’s claims or bona fide service fees.

SB45-SSA2-SA4,159,13 4. The amounts, including pharmacy access and audit recovery fees, received from all pharmacies that are in the pharmacy benefit manager’s network or have a contract to be in the network and, from these amounts, the amount retained by the pharmacy benefit manager and not passed through to the health benefit plan sponsor.

SB45-SSA2-SA4,245 Section 245. 632.868 of the statutes is created to read:

SB45-SSA2-SA4,159,15 632.868 Insulin safety net programs. (1) Definitions. In this section:

SB45-SSA2-SA4,159,17 (a) “Manufacturer” means a person engaged in the manufacturing of insulin that is self-administered on an outpatient basis.

SB45-SSA2-SA4,159,18 (b) “Navigator” has the meaning given in s. 628.90 (3).

SB45-SSA2-SA4,159,20 (c) “Patient assistance program” means a program established by a manufacturer under sub. (3) (a).

SB45-SSA2-SA4,159,21 (d) “Pharmacy” means an entity licensed under s. 450.06 or 450.065.

SB45-SSA2-SA4,160,2 (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.

SB45-SSA2-SA4,160,4 (f) “Urgent need safety net program” means a program established by a manufacturer under sub. (2) (a).

SB45-SSA2-SA4,160,8 (2) Urgent need safety net program. (a) Establishment of program. No later than July 1, 2026, 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).