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LRB-5192/1
TJD&EKL:cdc
2021 - 2022 LEGISLATURE
November 17, 2021 - Introduced by Representatives Kurtz, Swearingen, Goyke,
James, Petryk, Summerfield, Andraca, Baldeh, Behnke, Billings, Bowen,
Brandtjen, Cabral-Guevara, Callahan, Conley, Considine, Dittrich,
Doyle, Drake, Duchow, Edming, Emerson, Gundrum, Haywood, Hintz,
Kerkman, Kitchens, Knodl, Krug, Macco, Magnafici, B. Meyers, Milroy,
Moses, Mursau, L. Myers, Neubauer, Novak, Ohnstad, Oldenburg,
Ortiz-Velez, Plumer, Pope, Riemer, J. Rodriguez, Rozar, Schraa,
Shankland, Shelton, Skowronski, Snodgrass, Snyder, Spiros, Spreitzer,
Thiesfeldt, Tranel, Vining, Vruwink, Wichgers, Sinicki, Stubbs and Tusler,
cosponsored by Senators Darling, Marklein, Erpenbach, Bernier, Bewley,
Feyen, Jacque, Johnson, Nass, Petrowski, Pfaff, Ringhand, Roys, Smith, L.
Taylor
, Wirch, Wanggaard, Cowles and Carpenter. Referred to Committee
on Health.
AB718,1,2 1An Act to create 628.34 (5m) of the statutes; relating to: prohibiting certain
2practices relating to insurance coverage of clinician-administered drugs.
Analysis by the Legislative Reference Bureau
This bill prohibits certain practices relating to clinician-administered drugs
under the state's insurance unfair marketing and trade practices law. The bill
defines “clinician-administered drug” as an outpatient prescription drug, other than
a vaccine, that, due to medical necessity, cannot reasonably be self-administered by
the patient or an individual assisting the patient and is typically administered by an
authorized health care provider in a physician's office, hospital outpatient
department, or other clinical setting. Under the bill, an insurer offering a health
benefit plan, a pharmacy benefit manager, or an agent of the insurer or pharmacy
benefit manager may not do any of the following:
1. Refuse to authorize, approve, or pay a participating provider for providing
a covered clinician-administered drug and related services to an enrollee,
policyholder, or insured.
2. Condition, deny, restrict, refuse to authorize or approve, or reduce payment
to a participating provider for a covered clinician-administered drug and related
services when all criteria for medical necessity are met because the provider obtains
the drug from an entity that is not selected by the plan. Also prohibited are health
benefit plan designs that prevent participating providers from receiving
reimbursement for a covered clinician-administered drug and any related service at
an applicable rate as specified in the contract.
3. Impose coverage or benefit limitations, or require an enrollee, policyholder,
or insured to pay an additional fee, higher copay or coinsurance, second copay or

coinsurance, or penalty when obtaining a clinician-administered drug from an
authorized health care provider or pharmacy.
4. Require an enrollee, policyholder, or insured to pay an additional fee, higher
copay or coinsurance, second copay or coinsurance, or other form of a price increase
for a clinician-administered drug when the drug is not dispensed by a pharmacy or
acquired from an entity that is selected by the plan.
5. Interfere with an enrollee's, policyholder's, or insured's right to choose to
obtain a clinician-administered drug from a participating provider or pharmacy of
choice.
6. Limit or exclude coverage for a clinician-administered drug when not
dispensed by a pharmacy or acquired from an entity selected by the plan when the
drug would otherwise be covered.
7. Require a pharmacy to dispense a clinician-administered drug directly to an
enrollee, policyholder, insured, or the insured's agent with the intention that the
individual will transport the drug to a health care provider for administration.
8. Require or encourage the dispensing of a clinician-administered drug to an
enrollee, policyholder, or insured in a manner that is inconsistent with the federal
Drug Supply Chain Security Act.
9. Require that a clinician-administered drug be dispensed or administered to
an enrollee, policyholder, or insured in the residence of the enrollee, policyholder, or
insured or require the use of an infusion site external to the office or clinic of the
enrollee's, policyholder's, or insured's provider.
Under the bill, a participating provider is a provider who is under contract with
a defined network plan, preferred provider plan, or limited service health
organization to provide health care services, items, or supplies to enrollees of the
plan or organization or a clinic, hospital outpatient department, or pharmacy under
the common ownership or control of the provider.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB718,1 1Section 1 . 628.34 (5m) of the statutes is created to read:
AB718,2,22 628.34 (5m) Clinician-administered drugs. (a) In this subsection:
AB718,2,43 1. “Clinician-administered drug” means an outpatient prescription drug, other
4than a vaccine, that meets all of the following conditions:
AB718,2,75 a. Due to medical necessity as determined by the prescribing provider, the drug
6cannot reasonably be self-administered by the patient to whom the drug is
7prescribed or by an individual assisting the patient with the self-administration.
AB718,3,5
1b. Due to medical necessity as determined by the prescribing provider, the drug
2is typically administered by a health care provider who is authorized under the laws
3of this state, including when acting under the delegation and supervision of a
4physician, to administer the drug and is typically administered in a physician's
5office, hospital outpatient department, or other clinical setting.
AB718,3,66 2. “Health benefit plan” has the meaning given in s. 632.745 (11).
AB718,3,77 3. “Participating provider” means any of the following:
AB718,3,108 a. A provider that is under contract with a defined network plan, preferred
9provider plan, or limited service health organization to provide health care services,
10items, or supplies to enrollees of the plan or organization.
AB718,3,1211 b. A clinic, hospital outpatient department, or pharmacy under the common
12ownership or control of a provider described in subd. 3. a.
AB718,3,1313 4. “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
AB718,3,1414 5. “Provider” has the meaning given in s. 609.01 (5m).
AB718,3,1715 (b) No insurer offering a health benefit plan, pharmacy benefit manager, or
16agent or affiliate of the insurer or pharmacy benefit manager may do any of the
17following:
AB718,3,2018 1. Refuse to authorize, approve, or pay a participating provider for providing
19a covered clinician-administered drug and related services to an enrollee,
20policyholder, or insured.
AB718,4,321 2. Condition, deny, restrict, refuse to authorize or approve, or reduce payment
22to a participating provider for a covered clinician-administered drug and related
23services to an enrollee, policyholder, or insured when all criteria for medical
24necessity are met because the participating provider obtains the drug from an entity
25that is not selected by the plan. Any health benefit plan design that prevents

1participating providers from receiving reimbursement for a covered
2clinician-administered drug and any related service at an applicable rate as
3specified in the contract is prohibited under this subdivision.
AB718,4,84 3. Impose coverage or benefit limitations, or require an enrollee, policyholder,
5or insured to pay an additional fee, higher copay or coinsurance, second copay or
6coinsurance, or penalty when obtaining a clinician-administered drug from a
7participating provider authorized under the laws of this state to administer the drug
8or a pharmacy.
AB718,4,129 4. Require an enrollee, policyholder, or insured to pay an additional fee, higher
10copay or coinsurance, second copay or coinsurance, or other form of a price increase
11for a clinician-administered drug when the drug is not dispensed by a pharmacy or
12acquired from an entity selected by the plan.
AB718,4,1513 5. Interfere with the right of an enrollee, policyholder, or insured to choose to
14obtain a clinician-administered drug from the participating provider or pharmacy
15of choice, including by inducement, steering, or offering financial or other incentives.
AB718,4,1816 6. Limit or exclude coverage for a clinician-administered drug when not
17dispensed by a pharmacy or acquired from an entity selected by the plan when the
18drug would otherwise be covered.
AB718,4,2219 7. Require a pharmacy to dispense a clinician-administered drug directly to an
20enrollee, policyholder, or insured or agent of the insured with the intention that the
21enrollee, policyholder, or insured or agent of the insured will transport the
22medication to a health care provider for administration.
AB718,5,223 8. Require or encourage the dispensing of a clinician-administered drug to an
24enrollee, policyholder, or insured in a manner that is inconsistent with the supply

1chain security controls and chain of distribution set by the federal drug supply chain
2security act, 21 USC 360eee, et seq.
AB718,5,93 9. Require that a clinician-administered drug be dispensed or administered to
4an enrollee, policyholder, or insured in the residence of the enrollee, policyholder, or
5insured or require use of an infusion site external to the office, department, or clinic
6of the provider of the enrollee, policyholder, or insured. Nothing in this subdivision
7prohibits the insurer, pharmacy benefit manager, or agent of the insurer or
8pharmacy benefit manager from offering the use of a home infusion pharmacy or
9external infusion site.
AB718,5,1010 (End)
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