AB773: Bill Text

AB773,23,12 (c) The pharmacy benefit manager may not charge a participant or beneficiary of a pharmacy benefits plan or program that the pharmacy benefit manager serves a different copayment obligation or additional fee, or provide any inducement or financial incentive, for the participant or beneficiary to use a pharmacy or pharmacist in a particular network of pharmacies or pharmacists the pharmacy benefit manager has established to serve individuals in this state.

AB773,23,22 (5p) Gag clauses prohibited. A pharmacy benefit manager may not prohibit a pharmacy or pharmacist that dispenses a pharmaceutical product from, nor may a pharmacy benefit manager penalize the pharmacy or pharmacist for, informing an individual about the cost of the pharmaceutical product, the amount in reimbursement that the pharmacy or pharmacist receives for dispensing the pharmaceutical product, the cost and clinical efficacy of a less expensive alternative to the pharmaceutical product, or any difference between the cost to the individual under the individual's pharmacy benefits plan or program and the cost to the individual if the individual purchases the pharmaceutical product without making a claim for benefits under the individual's pharmacy benefits plan or program.

AB773,24,2 (5t) Exclusion of pharmacies prohibited. No pharmacy benefit manager, 3rd-party payer, or health benefit plan may exclude a pharmacy or pharmacist from its network because the pharmacy or pharmacist serves less than a certain portion of the population of the state or serves a population living with certain health conditions.

AB773,27 Section 27 . 632.865 (6) (bm) of the statutes is created to read:

AB773,24,5 632.865 (6) (bm) Requirements of audits. An entity that conducts audits of pharmacists of pharmacies shall ensure all of the following:

AB773,24,8 1. Each pharmacist or pharmacy audited by the entity is audited under the same standards and parameters as other similarly situated pharmacists or pharmacies audited by the entity.

AB773,24,10 2. The entity randomizes the prescriptions that the entity audits and the entity audits the same number of prescriptions in each prescription benefit tier.

AB773,24,13 3. Each audit of a prescription reimbursed under Part D of Medicare under 42 USC 1395w-101 et seq. is conducted separately from audits of prescriptions reimbursed under other policies or plans.

AB773,28 Section 28 . 632.865 (6) (c) 3. of the statutes is amended to read:

AB773,24,21 632.865 (6) (c) 3. Deliver to the pharmacist or pharmacy a final audit report, which may be delivered electronically, within 90 days of the date the pharmacist or pharmacy receives the preliminary report or the date of the final appeal of the audit, whichever is later. The final audit report under this subdivision shall include specific documentation of any alleged errors and shall include any response provided to the auditor by the pharmacy or pharmacist and consider and address the pharmacy's or pharmacist's response.

AB773,29 Section 29 . 632.865 (6) (c) 3m. of the statutes is created to read:

AB773,25,2 632.865 (6) (c) 3m. If an entity delivers to the pharmacist or pharmacy a preliminary report of the audit or final audit report that references a billing code, drug code, or other code associated with audits, the entity shall provide an electronic link to a plain language explanation of the code.

AB773,30 Section 30 . 632.865 (6g) of the statutes is created to read:

AB773,25,7 632.865 (6g) Recoupment. (a) No pharmacy benefit manager may recoup reimbursement made to a pharmacist or pharmacy for errors that have no actual financial harm to an enrollee, policy, or plan unless the error is the result of the pharmacist or pharmacy failing to comply with a formal corrective action plan.

AB773,25,12 (b) No pharmacy benefit manager may use extrapolation in calculating reimbursements that it may recoup. The finding of errors for which reimbursement will be recouped shall be based on an actual error in reimbursement and not on a projection of the number of patients served having a similar diagnosis or on a projection of the number of similar orders or refills for similar prescription drugs.

AB773,25,16 (c) A pharmacy benefit manager that recoups any reimbursement made to a pharmacist or pharmacy for an error that was the cause of financial harm shall return the recouped reimbursement to the individual or the policy or plan sponsor who was harmed by the error.

AB773,31 Section 31 . 632.865 (6r) of the statutes is created to read:

AB773,25,21 632.865 (6r) Quality programs. No pharmacy benefit manager may base any criteria of a quality program in a contract between a pharmacy and a pharmacy benefit manager on a factor for which the pharmacy does not have complete and exclusive control.

AB773,32 Section 32. 632.865 (8) of the statutes is created to read:

AB773,25,24 632.865 (8) Retaliation prohibited. (a) In this subsection, “retaliate” includes any of the following actions taken by a pharmacy benefit manager:

AB773,25,25 1. Terminating or refusing to renew a contract with a pharmacy or pharmacist.

AB773,26,1 2. Subjecting a pharmacy or pharmacist to increased audits.

AB773,26,3 3. Failing to promptly pay a pharmacy or pharmacist any money the pharmacy benefit manager owes to the pharmacy or pharmacist.

AB773,26,6 (b) A pharmacy benefit manager may not retaliate against a pharmacy or pharmacist for reporting an alleged violation of this section or for exercising a right or remedy under this section.

AB773,26,11 (c) In addition to any other remedies provided by law, a pharmacy or pharmacist may bring an action in court for injunctive relief based on a violation of par. (b). In addition to equitable relief, the court may, notwithstanding s. 814.04 (1), award a pharmacy or pharmacist that prevails in such an action reasonable attorney fees and costs in prosecuting the action.

AB773,33 Section 33. Initial applicability.

AB773,26,15 (1) Affiliated reimbursements. Except as provided in sub. (4 ), the treatment of s. 632.865 (2d) (d) first applies to a reimbursement amount paid for on a claim for reimbursement submitted on the effective date of this subsection.

AB773,26,18 (2) Professional dispensing fees. Except as provided in sub. (4 ), the treatment of s. 632.865 (2h) first applies to a pharmaceutical product that is dispensed on the effective date of this subsection.

AB773,26,21 (3) Pharmacy benefit manager-imposed fees. Except as provided in sub. (4 ), the treatment of s. 632.865 (2p) first applies to remuneration collected by a pharmacy benefit manager on the effective date of this subsection.

AB773,27,3 (4) Contracts. The treatment of ss. 632.861 (1m), (3g), (3r), and (4) (a) and (e) and 632.865 (1) (ab), (ac), (ae), (an), (aq), (at), (bm), (cg), and (cr), (2), (2d), (2h), (2p), (2t), (5) (e), (5d), (5h), (5p), (5t), (6) (bm) and (c) 3. and 3m., (6g), (6r), and (8), the renumbering of s. 632.865 (4), and the creation of s. 632.865 (4) (b) first apply to a pharmacy benefit manager that is affected by a contract that contains a provisions inconsistent with those treatments on the day on which the contract expires or is extended, modified, or renewed, whichever occurs first.

AB773,27,4 (5) Application of prescription drug payments.

AB773,27,8 (a) For policies and plans containing provisions inconsistent with the treatment of s. 632.862, that treatment first applies to policy or plan years beginning on January 1 of the year following the year in which this paragraph takes effect, except as provided in par. (b).

AB773,27,13 (b) For policies or plans that are affected by a collective bargaining agreement containing provisions inconsistent with the treatment of s. 632.862, that treatment first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is newly established, extended, modified, or renewed, whichever is later.

AB773,34 Section 34. Effective dates. This act takes effect on the day after publication, except as follows:

AB773,27,17 (1) Application of prescription drug payments. The treatment of s. 632.862 takes effect on the first day of the 4th month beginning after publication.

AB773,27,18 (End)