Chapter 49

49.685 History History: 1977 c. 213; 1979 c. 32; 1983 a. 27; 1983 a. 189 s. 329 (10); 1983 a. 544 s. 47 (1); 1985 a. 29 s. 3202 (23), (46); 1987 a. 27; 1987 a. 312 s. 17; 1993 a. 16, 449; 1995 a. 27 ss. 3048 to 3060; Stats. 1995 s. 49.685; 2001 a. 16; 2003 a. 33, 198.

49.685 Cross-reference Cross-reference: See also ch. DHS 153, Wis. adm. code.

49.686 49.686 AZT and pentamidine reimbursement program.

49.686(1) (1) Definitions. In this section:

49.686(1)(a) (a) “AIDS” means acquired immunodeficiency syndrome.

49.686(1)(am) (am) “AZT” means the drug azidothymidine.

49.686(1)(b) (b) “Gross income” means all income, from whatever source derived and in whatever form realized, whether in money, property or services.

49.686(1)(c) (c) “HIV” means any strain of human immunodeficiency virus, which causes acquired immunodeficiency syndrome.

49.686(1)(d) (d) “HIV infection” means the pathological state produced by a human body in response to the presence of HIV.

49.686(1)(e) (e) “Physician” has the meaning specified in s. 448.01 (5).

49.686(1)(f) (f) “Residence” means the concurrence of physical presence with intent to remain in a place of fixed habitation. Physical presence is prima facie evidence of intent to remain.

49.686(2) (2) Reimbursement. From the appropriation accounts under s. 20.435 (1) (am), (i), and (ma), the department may reimburse or supplement the reimbursement of the cost of AZT, the drug pentamidine, and any drug approved for reimbursement under sub. (4) (c) for an individual who is eligible under sub. (3).

49.686(3) (3) Eligibility. An individual is eligible to receive the reimbursement specified under sub. (2) if he or she meets all of the following criteria:

49.686(3)(a) (a) Has residence in this state.

49.686(3)(b) (b) Has an infection that is certified by a physician to be an HIV infection.

49.686(3)(c) (c) Has a prescription issued by a physician for AZT, for pentamidine or for a drug approved for reimbursement under sub. (4) (c).

49.686(3)(d) (d) Has applied for coverage under and has been denied eligibility for medical assistance within 12 months prior to application for reimbursement under sub. (2). This paragraph does not apply to an individual who is eligible for benefits under the demonstration project for childless adults under s. 49.45 (23) or to an individual who is eligible for benefits under BadgerCare Plus under s. 49.471 (11).

49.686(3)(e) (e) Has no insurance coverage for AZT, the drug pentamidine or any drug approved for reimbursement under sub. (4) (c) or, if he or she has insurance coverage, the coverage is inadequate to pay the full cost of the individual’s prescribed dosage of AZT, the drug pentamidine or any drug approved for reimbursement under sub. (4) (c).

49.686(3)(f) (f) Is an individual whose annual gross household income is at or below 200 percent of the poverty line and, if funding is available under s. 20.435 (1) (i) or (m), is an individual whose annual gross household income is above 200 percent and at or below 300 percent of the poverty line.

49.686(4) (4) Departmental duties. The department shall do all of the following:

49.686(4)(a) (a) Determine the eligibility of individuals applying for reimbursement, or a supplement to the reimbursement, of the costs of AZT or the drug pentamidine.

49.686(4)(b) (b) Within the limits of sub. (5) and of the funds specified under sub. (2) and under a schedule that the department shall establish based on the ability of individuals to pay, reimburse or supplement the reimbursement of the eligible individuals.

49.686(4)(c) (c) After consulting with individuals, including those not employed by the department, with expertise in issues relative to drugs for the treatment of HIV infection and AIDS, determine which, if any, drugs that are cost-effective alternatives to AZT and pentamidine may also have costs reimbursed under this section.

49.686(5) (5) Reimbursement limitation. Reimbursement may not be made under this section for any portion of the costs of AZT, the drug pentamidine or any drug approved for reimbursement under sub. (4) (c) which are payable by an insurer, as defined in s. 600.03 (27).

49.686 History History: 1989 a. 31; 1991 a. 39; 1993 a. 16; 1995 a. 27 ss. 3061 to 3062d; Stats. 1995 s. 49.686; 1997 a. 27; 2001 a. 81; 2007 a. 20, 89; 2009 a. 28, 209; 2013 a. 20.

49.687 49.687 Disease aids; patient requirements; rebate agreements; cost containment.

49.687(1) (1) The department shall promulgate rules that require a person who is eligible for benefits under s. 49.68, 49.683, or 49.685 and whose estimated total family income for the current year is at or above 200 percent of the poverty line to obligate or expend specified portions of the income for medical care for treatment of kidney disease, cystic fibrosis, or hemophilia before receiving benefits under s. 49.68, 49.683, or 49.685. The rules shall require a person to pay 0.50 percent of his or her total family income for the cost of medical treatment covered under s. 49.68, 49.683, or 49.685 if that income is from 200 percent to 250 percent of the federal poverty line, 0.75 percent if that income is more than 250 percent but not more than 275 percent of the federal poverty line, 1 percent if that income is more than 275 percent but not more than 300 percent of the federal poverty line, 1.25 percent if that income is more than 300 percent but not more than 325 percent of the federal poverty line, 2 percent if that income is more than 325 percent but not more than 350 percent of the federal poverty line, 2.75 percent if that income is more than 350 percent but not more than 375 percent of the federal poverty line, 3.5 percent if that income is more than 375 percent but not more than 400 percent of the federal poverty line, and 4.5 percent if that income is more than 400 percent of the federal poverty line.

49.687(1m) (1m) 

49.687(1m)(a) (a) A person is not eligible to receive benefits under s. 49.68 or 49.683 unless before the person applies for benefits under s. 49.68 or 49.683, the person first applies for benefits under all other health care coverage programs specified by the department by rule for which the person reasonably may be eligible.

49.687(1m)(b) (b) The department shall promulgate rules that specify other health care coverage programs for which a person must apply before applying for benefits under s. 49.685. The department may waive the requirement under this paragraph for an applicant who requests a waiver for religious reasons.

49.687(1m)(c) (c) Using the procedure under s. 227.24, the department may promulgate rules under par. (b) for the period before the effective date of any permanent rules promulgated under par. (b), but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under par. (b) as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to make a finding of emergency for promulgating a rule under par. (b) as an emergency rule.

49.687(2) (2) The department shall develop and implement a sliding scale of patient liability for kidney disease aid under s. 49.68, cystic fibrosis aid under s. 49.683, and hemophilia treatment under s. 49.685, based on the patient’s ability to pay for treatment. The department shall continuously review the sliding scale for patient liability and revise it as needed to ensure that the amounts budgeted under s. 20.435 (4) (e) and (je) are sufficient to cover treatment costs.

49.687(2m) (2m) If a pharmacy directly bills the department or an entity with which the department contracts for a drug supplied to a person receiving benefits under s. 49.68, 49.683, or 49.685 and prescribed for treatment covered under s. 49.68, 49.683, or 49.685, the person shall pay a $7.50 copayment amount for each such generic drug and a $15 copayment amount for each such brand name drug.

49.687(3) (3) The department or an entity with which the department contracts shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department or entity that is modeled on the rebate agreement specified under 42 USC 1396r-8. The department or entity may enter into a rebate agreement under this subsection that shall include all of the following as requirements:

49.687(3)(a) (a) That, as a condition of coverage for prescription drugs of a manufacturer under s. 49.68, 49.683, or 49.685, the manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons who meet eligibility criteria under s. 49.68, 49.683, or 49.685, to the secretary of administration to be credited to the appropriation under s. 20.435 (4) (je), each calendar quarter or according to a schedule established by the department.

49.687(3)(b) (b) That the amount of the rebate payment shall be determined by a method specified in 42 USC 1396r-8 (c).

49.687(4) (4) The department may adopt managed care methods of cost containment for the programs under ss. 49.68, 49.683, and 49.685.

49.687(6) (6) The department shall obtain and share information about individuals who receive benefits under s. 49.68, 49.683, or 49.685 as provided in s. 49.475.

49.687 History History: 1983 a. 27; 1989 a. 56; 1991 a. 39; 1993 a. 16, 449; 1995 a. 27 ss. 3063 to 3065; Stats. 1995 s. 49.687; 1997 a. 27; 1999 a. 9; 2001 a. 16; 2003 a. 33, 198; 2007 a. 20.

49.687 Cross-reference Cross-reference: See also ch. DHS 154, Wis. adm. code.

49.688 49.688 Prescription drug assistance for elderly persons.

49.688(1) (1) In this section:

49.688(1)(a) (a) “Generic name” has the meaning given in s. 450.12 (1) (b).

49.688(1)(b) (b) “Poverty line” means the nonfarm federal poverty line for the continental United States, as defined in 42 USC 9902 (2).

49.688(1)(c) (c) “Prescription drug” means any of the following:

49.688(1)(c)1. 1. A prescription drug, as defined in s. 450.01 (20), that is included in the drugs specified under s. 49.46 (2) (b) 6. h. and that is manufactured by a drug manufacturer that enters into a rebate agreement in force under sub. (6).

49.688(1)(c)2. 2. A vaccination recommended for administration to adults by the federal centers for disease control and prevention’s advisory committee on immunization practices and approved for administration to adults by the department.

49.688(1)(d) (d) “Prescription order” has the meaning given in s. 450.01 (21).

49.688(1)(e) (e) “Program payment rate” means the rate of payment made for the identical drug specified under s. 49.46 (2) (b) 6. h. plus a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under s. 49.46 (2) (b) 6. h.

49.688(2) (2) 

49.688(2)(a) (a) A person to whom all of the following applies is eligible to purchase a prescription drug for the amounts specified in sub. (5) (a) 1. and 2.:

49.688(2)(a)1. 1. The person is a resident, as defined in s. 27.01 (10) (a), of this state.

49.688(2)(a)2. 2. The person is at least 65 years of age.

49.688(2)(a)3. 3. The person is not a recipient of medical assistance or, as a recipient, does not receive prescription drug coverage.

49.688(2)(a)4. 4. The person’s annual household income, as determined by the department, does not exceed 240 percent of the federal poverty line for a family the size of the person’s eligible family.

49.688(2)(a)5. 5. The person pays the program enrollment fee specified in sub. (3) (a).

49.688(2)(b) (b) A person to whom par. (a) 1. to 3. and 5. applies, but whose annual household income, as determined by the department, exceeds 240 percent of the federal poverty line for a family the size of the persons’ eligible family, is eligible to purchase a prescription drug at the amounts specified in sub. (5) (a) 4. only during the remaining amount of any 12-month period in which the person has first paid the annual deductible specified in sub. (3) (b) 2. a. in purchasing prescription drugs at the retail price and has then paid the annual deductible specified in sub. (3) (b) 2. b.

49.688(3) (3) Program participants shall pay all of the following:

49.688(3)(a) (a) For each 12-month benefit period, a program enrollment fee of $30.

49.688(3)(b) (b)

49.688(3)(b)1. 1. For each 12-month benefit period, for a person specified in sub. (2) (a), a deductible for prescription drugs that is based on the percentage that a person’s annual household income, as determined by the department, is of the federal poverty line for a family the size of the person’s eligible family, as follows:

49.688(3)(b)1.a. a. One hundred sixty percent or less, no deductible.

49.688(3)(b)1.b. b. More than 160 percent, but not more than 200 percent, $500.

49.688(3)(b)1.c. c. More than 200 percent, but not more than 240 percent, $850.

49.688(3)(b)2. 2. For each 12-month benefit period, for a person specified in sub. (2) (b), a deductible for prescription drugs that equals all of the following:

49.688(3)(b)2.a. a. The difference between the person’s annual household income and 240 percent of the federal poverty line for a family the size of the person’s eligible family.

49.688(3)(b)2.b. b. Eight hundred fifty dollars.

49.688(3)(c) (c) After payment of any applicable deductible under par. (b), all of the following:

49.688(3)(c)1. 1. A copayment of $5 for each prescription drug that bears only a generic name.

49.688(3)(c)2. 2. A copayment of $15 for each prescription drug that does not bear only a generic name.

49.688(3)(d) (d) If a person who is eligible under this section has other available coverage for payment of a prescription drug, this section applies only to costs for prescription drugs for the person that are not covered under the person’s other available coverage.

49.688(3m) (3m) Per a prescription order by the prescribing health care provider, a person eligible under sub. (2) may purchase, and a pharmacist, pharmacy, or dispensing physician may dispense, a prescription drug authorized under administrative rules promulgated by the department and otherwise covered under this section at the rates provided in this section in amounts up to a 100-day supply.

49.688(4) (4) The department shall devise and distribute a form for application for the program under sub. (2), shall determine eligibility for each 12-month benefit period of applicants and shall issue to eligible persons a prescription drug card for use in purchasing prescription drugs, as specified in sub. (5). The department shall promulgate rules that specify the criteria to be used to determine household income under sub. (2) (a) 4. and (b) and (3) (b) 1.

49.688(5) (5) 

49.688(5)(a) (a) Beginning on September 1, 2002, except as provided in sub. (7) (b), as a condition of participation by a pharmacy or pharmacist in the program under s. 49.45, 49.46, 49.47, or 49.471, the pharmacy or pharmacist may not charge a person who presents a valid prescription order and a card indicating that he or she meets eligibility requirements under sub. (2) an amount for a prescription drug under the order that exceeds the following:

49.688(5)(a)1. 1. For a deductible, as specified in sub. (3) (b) 1. and 2. b., the program payment rate.

49.688(5)(a)2. 2. After any applicable deductible under subd. 1. is charged, the copayment, as applicable, that is specified in sub. (3) (c) 1. or 2. No dispensing fee may be charged to a person under this subdivision.

49.688(5)(a)3. 3. For a deductible, as specified in sub. (3) (b) 2. a., the retail price.

49.688(5)(a)4. 4. After the deductible under subd. 3. is charged, the copayment, as applicable, that is specified in sub. (3) (c) 1. or 2. No dispensing fee may be charged to a person under this subdivision.

49.688(5)(b) (b) The department shall calculate and transmit to pharmacies and pharmacists that are certified providers of medical assistance amounts that may be used in calculating charges under par. (a). The department shall periodically update this information and transmit the updated amounts to pharmacies and pharmacists.

49.688(6) (6) The department, or an entity with which the department contracts, shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department or entity that is modeled on the rebate agreement specified under 42 USC 1396r-8. A rebate agreement under this subsection shall include all of the following as requirements:

49.688(6)(a) (a) That, except as provided in sub. (7) (b), the manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons who meet criteria under sub. (2) (a) and persons who meet criteria under sub. (2) (b) and have paid the deductible under sub. (3) (b) 2. a., to the secretary of administration to be credited to the appropriation account under s. 20.435 (4) (j), each calendar quarter or according to a schedule established by the department.

49.688(6)(b) (b) That, except as provided in sub. (7) (b), the amount of the rebate payment shall be determined by a method specified in 42 USC 1396r-8 (c).

49.688(7) (7) 

49.688(7)(a) (a) Except as provided in par. (b), from the appropriation accounts under s. 20.435 (4) (bv), (j), and (pg), beginning on September 1, 2002, the department shall, under a schedule that is identical to that used by the department for payment of pharmacy provider claims under medical assistance, provide to pharmacies and pharmacists payments for prescription drugs sold by the pharmacies or pharmacists to persons eligible under sub. (2) who have paid the deductible specified under sub. (3) (b) 1. or 2. or who, under sub. (3) (b) 1., are not required to pay a deductible. The payment for each prescription drug under this paragraph shall be at the program payment rate, minus any copayment paid by the person under sub. (5) (a) 2. or 4., and plus, if applicable, incentive payments that are similar to those provided under s. 49.45 (8v). The department shall devise and distribute a claim form for use by pharmacies and pharmacists under this paragraph and may limit payment under this paragraph to those prescription drugs for which payment claims are submitted by pharmacists or pharmacies directly to the department. The department may apply to the program under this section the same utilization and cost control procedures that apply under rules promulgated by the department to medical assistance under subch. IV of ch. 49.

49.688(7)(b) (b) During any period in which funding under s. 20.435 (4) (bv) and (pg) is completely expended for the payments specified in par. (a), the requirements of par. (a) and subs. (3) (c), (5), and (6) (a) and (b) do not apply to drugs purchased during that period, but the department shall continue to accept applications and determine eligibility under sub. (4) and shall indicate to applicants that the eligibility of program participants to purchase prescription drugs as specified in sub. (3), under the requirements of sub. (5), is conditioned on the availability of funding under s. 20.435 (4) (bv) and (pg).

49.688(8m) (8m) The department shall obtain and share information about participants in the program under this section as provided in s. 49.475.

49.688(9) (9) 

49.688(9)(a) (a) The department shall promulgate rules relating to prohibitions on fraud that are substantially similar to applicable provisions under s. 946.91 (2).