AB50-ASA2-AA11,21,7233. A pharmacy that dispenses insulin under subd. 2. may submit to the
1manufacturer, or the manufacturer’s vendor, a claim for payment that is in 2accordance with the national council for prescription drug programs’ standards for 3electronic claims processing, except that no claim may be submitted if the 4manufacturer agrees to send the pharmacy a replacement of the same insulin in 5the amount dispensed. If the pharmacy submits an electronic claim, the 6manufacturer or vendor shall reimburse the pharmacy in an amount that covers 7the pharmacy’s acquisition cost. AB50-ASA2-AA11,21,984. A pharmacy that dispenses insulin under subd. 2. shall retain a copy of the 9application form described in subd. 1. a. AB50-ASA2-AA11,21,1610(d) Eligibility of certain individuals. An individual who has applied for public 11assistance under ch. 49 but for whom a determination of eligibility has not been 12made or whose coverage has not become effective or an individual who has an 13appeal pending under sub. (3) (c) 4. may access insulin under this subsection if the 14individual is in urgent need of insulin. To access a 30-day supply of insulin, the 15individual shall attest to the pharmacy that the individual is described in this 16paragraph and comply with par. (c) 1. AB50-ASA2-AA11,21,2117(3) Patient assistance program. (a) Establishment of program. No later 18than July 1, 2026, each manufacturer shall establish a patient assistance program 19to make insulin available in accordance with this subsection to individuals who 20meet the eligibility requirements under par. (b). Under the patient assistance 21program, the manufacturer shall do all of the following: AB50-ASA2-AA11,22,2221. Provide the commissioner with information regarding the patient
1assistance program, including contact information for individuals to call for 2assistance in accessing the patient assistance program. AB50-ASA2-AA11,22,432. Provide a hotline for individuals to call or access between 8 a.m. and 10 p.m. 4on weekdays and between 10 a.m. and 6 p.m. on Saturdays. AB50-ASA2-AA11,22,653. List the eligibility requirements under par. (b) on the manufacturer’s 6website. AB50-ASA2-AA11,22,1074. Maintain the privacy of all information received from an individual 8applying for or participating in the patient assistance program and not sell, share, 9or disseminate the information unless required under this section or authorized, in 10writing, by the individual. AB50-ASA2-AA11,22,1211(b) Eligible individual. An individual shall be eligible to receive insulin under 12a patient assistance program if all of the following conditions are met: AB50-ASA2-AA11,22,13131. The individual is a resident of this state. AB50-ASA2-AA11,22,16142. The individual, or the individual’s parent or legal guardian if the individual 15is under the age of 18, has a valid Wisconsin driver’s license or state identification 16card. AB50-ASA2-AA11,22,17173. The individual has a valid insulin prescription. AB50-ASA2-AA11,22,20184. The family income of the individual does not exceed 400 percent of the 19poverty line as defined and revised annually under 42 USC 9902 (2) for a family the 20size of the individual’s family. AB50-ASA2-AA11,22,21215. The individual is not receiving public assistance under ch. 49. AB50-ASA2-AA11,23,4226. The individual is not eligible to receive health care through a federally 23funded program or receive prescription drug benefits through the U.S. department
1of veterans affairs, except that this subdivision does not apply to an individual who 2is enrolled in a policy under Part D of Medicare under 42 USC 1395w-101 et seq. if 3the individual has spent at least $1,000 on prescription drugs in the current 4calendar year. AB50-ASA2-AA11,23,957. The individual is not enrolled in prescription drug coverage through an 6individual or group health plan that limits the total cost sharing amount, including 7copayments, deductibles, and coinsurance, that an enrollee is required to pay for a 830-day supply of insulin to no more than $75, regardless of the type or amount of 9insulin needed. AB50-ASA2-AA11,23,1910(c) Application for patient assistance program. 1. An individual may apply to 11participate in a patient assistance program by filing an application with the 12manufacturer that established the patient assistance program, the individual’s 13health care practitioner if the practitioner participates in the patient assistance 14program, or a navigator included on the list under sub. (8) (c). A health care 15practitioner or navigator shall immediately submit the application to the 16manufacturer. Upon receipt of an application, the manufacturer shall determine 17the individual’s eligibility under par. (b) and, except as provided in subd. 2., notify 18the individual of the determination no later than 10 days after receipt of the 19application. AB50-ASA2-AA11,24,2202. If necessary to determine the individual’s eligibility under par. (b), the 21manufacturer may request additional information from an individual who has filed 22an application under subd. 1. no later than 5 days after receipt of the application. 23Upon receipt of the additional information, the manufacturer shall determine the
1individual’s eligibility under par. (b) and notify the individual of the determination 2no later than 3 days after receipt of the requested information. AB50-ASA2-AA11,24,833. Except as provided in subd. 5., if the manufacturer determines under subd. 41. or 2. that the individual is eligible for the patient assistance program, the 5manufacturer shall provide the individual with a statement of eligibility. The 6statement of eligibility shall be valid for 12 months and may be renewed upon a 7determination by the manufacturer that the individual continues to meet the 8eligibility requirements under par. (b). AB50-ASA2-AA11,24,1994. If the manufacturer determines under subd. 1. or 2. that the individual is 10not eligible for the patient assistance program, the manufacturer shall provide the 11reason for the determination in the notification under subd. 1. or 2. The individual 12may appeal the determination by filing an appeal with the commissioner that shall 13include all of the information provided to the manufacturer under subds. 1. and 2. 14The commissioner shall establish procedures for deciding appeals under this 15subdivision. The commissioner shall issue a decision no later than 10 days after the 16appeal is filed, and the commissioner’s decision shall be final. If the commissioner 17determines that the individual meets the eligibility requirements under par. (b), the 18manufacturer shall provide the individual with the statement of eligibility 19described in subd. 3. AB50-ASA2-AA11,25,5205. In the case of an individual who has prescription drug coverage through an 21individual or group health plan, if the manufacturer determines under subd. 1. or 2. 22that the individual is eligible for the patient assistance program but also 23determines that the individual’s insulin needs are better addressed through the use
1of the manufacturer’s copayment assistance program rather than the patient 2assistance program, the manufacturer shall inform the individual of the 3determination and provide the individual with the necessary coupons to submit to 4a pharmacy. The individual may not be required to pay more than the copayment 5amount specified in par. (d) 2. AB50-ASA2-AA11,25,126(d) Provision of insulin under a patient assistance program. 1. Upon receipt 7from an individual of the eligibility statement described in par. (c) 3. and a valid 8insulin prescription, a pharmacy shall submit an order containing the name of the 9insulin and daily dosage amount to the manufacturer. The pharmacy shall include 10with the order the pharmacy’s name, shipping address, office telephone number, 11fax number, email address, and contact name, as well as any days or times when 12deliveries are not accepted by the pharmacy. AB50-ASA2-AA11,25,21132. Upon receipt of an order meeting the requirements under subd. 1., the 14manufacturer shall send the pharmacy a 90-day supply of insulin, or lesser amount 15if requested in the order, at no charge to the individual or pharmacy. The pharmacy 16shall dispense the insulin to the individual associated with the order. The insulin 17shall be dispensed at no charge to the individual, except that the pharmacy may 18collect a copayment from the individual to cover the pharmacy’s costs for processing 19and dispensing in an amount not to exceed $50 for each 90-day supply of insulin. 20The pharmacy may not seek reimbursement from the manufacturer or a 3rd-party 21payer. AB50-ASA2-AA11,26,2223. The pharmacy may submit a reorder to the manufacturer if the individual’s
1eligibility statement described in par. (c) 3. has not expired. The reorder shall be 2treated as an order for purposes of subd. 2. AB50-ASA2-AA11,26,534. Notwithstanding subds. 2. and 3., a manufacturer may send the insulin 4directly to the individual if the manufacturer provides a mail-order service option, 5in which case the pharmacy may not collect a copayment from the individual. AB50-ASA2-AA11,26,86(4) Exceptions. (a) This section does not apply to a manufacturer that shows 7to the commissioner’s satisfaction that the manufacturer’s annual gross revenue 8from insulin sales in this state does not exceed $2,000,000. AB50-ASA2-AA11,26,139(b) A manufacturer may not be required to make an insulin product available 10under sub. (2) or (3) if the wholesale acquisition cost of the insulin product does not 11exceed $8, as adjusted annually based on the U.S. consumer price index for all 12urban consumers, U.S. city average, per milliliter or the applicable national council 13for prescription drug programs’ plan billing unit. AB50-ASA2-AA11,26,1614(5) Confidentiality. All medical information solicited or obtained by any 15person under this section shall be subject to the applicable provisions of state law 16relating to confidentiality of medical information, including s. 610.70. AB50-ASA2-AA11,26,2217(6) Reimbursement prohibition. No person, including a manufacturer, 18pharmacy, pharmacist, or 3rd-party administrator, as part of participating in an 19urgent need safety net program or patient assistance program may request or seek, 20or cause another person to request or seek, any reimbursement or other 21compensation for which payment may be made in whole or in part under a federal 22health care program, as defined in 42 USC 1320a-7b (f). AB50-ASA2-AA11,27,223(7) Reports. (a) Annually, no later than March 1, each manufacturer shall
1report to the commissioner all of the following information for the previous calendar 2year: AB50-ASA2-AA11,27,431. The number of individuals who received insulin under the manufacturer’s 4urgent need safety net program. AB50-ASA2-AA11,27,752. The number of individuals who sought assistance under the 6manufacturer’s patient assistance program and the number of individuals who 7were determined to be ineligible under sub. (3) (c) 4. AB50-ASA2-AA11,27,983. The wholesale acquisition cost of the insulin provided by the manufacturer 9through the urgent need safety net program and patient assistance program. AB50-ASA2-AA11,27,1310(b) Annually, no later than April 1, the commissioner shall submit to the 11governor and the chief clerk of each house of the legislature, for distribution to the 12legislature under s. 13.172 (2), a report on the urgent need safety net programs and 13patient assistance programs that includes all of the following: AB50-ASA2-AA11,27,14141. The information provided to the commissioner under par. (a). AB50-ASA2-AA11,27,16152. The penalties assessed under sub. (9) during the previous calendar year, 16including the name of the manufacturer and amount of the penalty. AB50-ASA2-AA11,27,2117(8) Additional responsibilities of commissioner. (a) Application form. 18The commissioner shall make the application form described in sub. (2) (c) 1. a. 19available on the office’s website and shall make the form available to pharmacies 20and health care providers who prescribe or dispense insulin, hospital emergency 21departments, urgent care clinics, and community health clinics. AB50-ASA2-AA11,28,222(b) Public outreach. 1. The commissioner shall conduct public outreach to
1create awareness of the urgent need safety net programs and patient assistance 2programs. AB50-ASA2-AA11,28,432. The commissioner shall develop and make available on the office’s website 4an information sheet that contains all of the following information: AB50-ASA2-AA11,28,65a. A description of how to access insulin through an urgent need safety net 6program. AB50-ASA2-AA11,28,87b. A description of how to access insulin through a patient assistance 8program. AB50-ASA2-AA11,28,109c. Information on how to contact a navigator for assistance in accessing 10insulin through an urgent need safety net program or patient assistance program. AB50-ASA2-AA11,28,1211d. Information on how to contact the commissioner if a manufacturer 12determines that an individual is not eligible for a patient assistance program. AB50-ASA2-AA11,28,1413e. A notification that an individual may contact the commissioner for more 14information or assistance in accessing ongoing affordable insulin options. AB50-ASA2-AA11,28,2115(c) Navigators. The commissioner shall develop a training program to provide 16navigators with information and the resources necessary to assist individuals in 17accessing appropriate long-term insulin options. The commissioner shall compile a 18list of navigators that have completed the training program and are available to 19assist individuals in accessing affordable insulin coverage options. The list shall be 20made available on the office’s website and to pharmacies and health care 21practitioners who dispense and prescribe insulin. AB50-ASA2-AA11,29,422(d) Satisfaction surveys. 1. The commissioner shall develop and conduct a 23satisfaction survey of individuals who have accessed insulin through urgent need
1safety net programs and patient assistance programs. The survey shall ask 2whether the individual is still in need of a long-term solution for affordable insulin 3and shall include questions about the individual’s satisfaction with all of the 4following, if applicable: AB50-ASA2-AA11,29,55a. Accessibility to urgent-need insulin. AB50-ASA2-AA11,29,76b. Adequacy of the information sheet and list of navigators received from the 7pharmacy. AB50-ASA2-AA11,29,88c. Helpfulness of a navigator. AB50-ASA2-AA11,29,109d. Ease of access in applying for a patient assistance program and receiving 10insulin from the pharmacy under the patient assistance program. AB50-ASA2-AA11,29,14112. The commissioner shall develop and conduct a satisfaction survey of 12pharmacies that have dispensed insulin through urgent need safety net programs 13and patient assistance programs. The survey shall include questions about the 14pharmacy’s satisfaction with all of the following, if applicable: AB50-ASA2-AA11,29,1615a. Timeliness of reimbursement from manufacturers for insulin dispensed by 16the pharmacy under urgent need safety net programs. AB50-ASA2-AA11,29,1717b. Ease in submitting insulin orders to manufacturers. AB50-ASA2-AA11,29,1818c. Timeliness of receiving insulin orders from manufacturers. AB50-ASA2-AA11,29,20193. The commissioner may contract with a nonprofit entity to develop and 20conduct the surveys under subds. 1. and 2. and to evaluate the survey results. AB50-ASA2-AA11,29,23214. No later than July 1, 2028, the commissioner shall submit to the governor 22and the chief clerk of each house of the legislature, for distribution to the legislature 23under s. 13.172 (2), a report on the results of the surveys under subds. 1. and 2. AB50-ASA2-AA11,30,5
1(9) Penalty. A manufacturer that violates this section may be required to 2forfeit not more than $200,000 per month of violation, with the maximum forfeiture 3increasing to $400,000 per month if the manufacturer continues to be in violation 4after 6 months and increasing to $600,000 per month if the manufacturer continues 5to be in violation after one year. AB50-ASA2-AA11,116Section 11. 632.895 (6) (title) of the statutes is amended to read: AB50-ASA2-AA11,30,87632.895 (6) (title) Equipment and supplies for treatment of diabetes; 8insulin. AB50-ASA2-AA11,129Section 12. 632.895 (6) of the statutes is renumbered 632.895 (6) (a) and 10amended to read: AB50-ASA2-AA11,30,2111632.895 (6) (a) Every disability insurance policy which that provides coverage 12of expenses incurred for treatment of diabetes shall provide coverage for expenses 13incurred by the installation and use of an insulin infusion pump, coverage for all 14other equipment and supplies, including insulin or any other prescription 15medication, used in the treatment of diabetes, and coverage of diabetic self-16management education programs. Coverage Except as provided in par. (b), 17coverage required under this subsection shall be subject to the same exclusions, 18limitations, deductibles, and coinsurance provisions of the policy as other covered 19expenses, except that insulin infusion pump coverage may be limited to the 20purchase of one pump per year and the insurer may require the insured to use a 21pump for 30 days before purchase. AB50-ASA2-AA11,30,2323632.895 (6) (b) 1. In this paragraph: AB50-ASA2-AA11,31,3
1a. “Cost sharing” means the total of any deductible, copayment, or 2coinsurance amounts imposed on a person covered under a disability insurance 3policy or self-insured health plan. AB50-ASA2-AA11,31,44b. “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). AB50-ASA2-AA11,31,752. Every disability insurance policy and self-insured health plan that covers 6insulin and imposes cost sharing on prescription drugs may not impose cost sharing 7on insulin in an amount that exceeds $35 for a one-month supply of insulin. AB50-ASA2-AA11,31,1183. Nothing in this paragraph prohibits a disability insurance policy or self-9insured health plan from imposing cost sharing on insulin in an amount less than 10the amount specified under subd. 2. Nothing in this paragraph requires a disability 11insurance policy or self-insured health plan to impose any cost sharing on insulin. AB50-ASA2-AA11,31,1913(1) Staggered terms for prescription drug affordability review board. 14Notwithstanding the length of terms specified for the members of the prescription 15drug affordability review board under s. 15.735 (1) (b) to (e), 2 of the initial 16members shall be appointed for terms expiring on May 1, 2027; 2 of the initial 17members shall be appointed for terms expiring on May 1, 2028; 2 of the initial 18members shall be appointed for terms expiring on May 1, 2029; and 2 of the initial 19members shall be appointed for terms expiring on May 1, 2030. AB50-ASA2-AA11,32,320(2) Prescription drug importation program. The commissioner of 21insurance shall submit the first report required under s. 601.575 (5) by the next 22January 1 or July 1, whichever is earliest, that is at least 180 days after the date the 23prescription drug importation program is fully operational under s. 601.575 (4).
1The commissioner of insurance shall include in the first 3 reports submitted under 2s. 601.575 (5) information on the implementation of the audit functions under s. 3601.575 (1) (n). AB50-ASA2-AA11,32,64(3) Prescription drug purchasing entity. During the 2025-27 fiscal 5biennium, the office of the commissioner of insurance shall conduct a study on the 6viability of creating or implementing a state prescription drug purchasing entity. AB50-ASA2-AA11,32,198(1) Office of prescription drug affordability. In the schedule under s. 920.005 (3) for the appropriation to the office of the commissioner of insurance under 10s. 20.145 (1) (g), the dollar amount for fiscal year 2025-26 is increased by $1,957,300 11to provide $500,000 in onetime implementation costs for establishing an office of 12prescription drug affordability in the office of the commissioner of insurance and 13$1,457,300 to authorize 16.0 PR positions within the office of prescription drug 14affordability, including 5.0 insurance examiners, 4.0 policy initiatives advisors, 2.0 15attorneys, 1.0 insurance program manager, 2.0 insurance administrators, and 2.0 16operations program associates. In the schedule under s. 20.005 (3) for the 17appropriation to the office of the commissioner of insurance under s. 20.145 (1) (g), 18the dollar amount for fiscal year 2026-27 is increased by $1,871,100 to fund the 19positions authorized under this subsection. AB50-ASA2-AA11,32,2421(1) Prescription drug affordability review board. The treatment of ss. 2215.07 (3) (bm) 7., 15.735, 601.78, 601.785, and 601.79 and subch. VI (title) of ch. 601 23and Section 9123 (1) of this act take effect on the first day of the 7th month 24beginning after publication. AB50-ASA2-AA11,33,4
1(2) Cost-sharing cap on insulin. The treatment of ss. 609.83 and 632.895 2(6) (title), the renumbering and amendment of s. 632.895 (6), and the creation of s. 3632.895 (6) (b) take effect on the first day of the 4th month beginning after 4publication.”.
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