SB737,,1616609.83 Coverage of drugs and devices; application of payments. Limited service health organizations, preferred provider plans, and defined network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and (16v).
SB737,717Section 7. 632.861 (1m) of the statutes is created to read:
SB737,,1818632.861 (1m) Required disclosures. A disability insurance policy or self-insured health plan that provides a prescription drug benefit shall make the formulary and all drug costs associated with the formulary available to plan sponsors and individuals prior to selection or enrollment.
SB737,819Section 8. 632.861 (3g) of the statutes is created to read:
SB737,,2020632.861 (3g) Choice of provider; penalty prohibited. No insurer, self-insured health plan, or pharmacy benefit manager may require, or penalize a person who is covered under a disability insurance policy or self-insured health plan for using or for not using, a specific retail, specific mail-order, or other specific pharmacy provider within the network of pharmacy providers under the policy or plan. A prohibited penalty under this subsection includes an increase in premium, deductible, copayment, or coinsurance.
SB737,921Section 9. 632.861 (3r) of the statutes is created to read:
SB737,,2222632.861 (3r) Pharmacy networks. (a) If an enrollee utilizes a pharmacy or pharmacist in a preferred network of pharmacies or pharmacists, no disability insurance policy or self-insured health plan that provides a prescription drug benefit or pharmacy benefit manager that provides services under a contract with a policy or plan may require the enrollee to pay any amount or impose on the enrollee any condition that would not be required if the enrollee utilized a different pharmacy or pharmacist in the same preferred network.
SB737,,2323(b) Any disability insurance policy or self-insured health plan that provides a prescription drug benefit, or any pharmacy benefit manager that provides services under a contract with a policy or plan, that has established a preferred network of pharmacies or pharmacists shall reimburse each pharmacy or pharmacist in the same network at the same rates.
SB737,1024Section 10. 632.861 (4) (a) of the statutes is amended to read:
SB737,,2525632.861 (4) (a) Except as provided in par. (b) and subject to par. (e), a disability insurance policy that offers a prescription drug benefit, a self-insured health plan that offers a prescription drug benefit, or a pharmacy benefit manager acting on behalf of a disability insurance policy or self-insured health plan shall provide to an enrollee advanced written notice of a formulary change that removes a prescription drug from the formulary of the policy or plan or that reassigns a prescription drug to a benefit tier for the policy or plan that has a higher deductible, copayment, or coinsurance. The advanced written notice of a formulary change under this paragraph shall be provided no fewer than 30 90 days before the expected date of the removal or reassignment and shall include information on the procedure for the enrollee to request an exception to the formulary change. The policy, plan, or pharmacy benefit manager is required to provide the advanced written notice under this paragraph only to those enrollees in the policy or plan who are using the drug at the time the notification must be sent according to available claims history.
SB737,1126Section 11. 632.861 (4) (e) of the statutes is created to read:
SB737,,2727632.861 (4) (e) No disability insurance policy, self-insured health plan, or pharmacy benefit manager acting on behalf of a disability insurance policy or self-insured health plan may remove a prescription drug from the formulary except at the time of coverage renewal.
SB737,1228Section 12. 632.862 of the statutes is created to read:
SB737,,2929632.862 Application of prescription drug payments. (1) Definitions. In this section:
SB737,,3030(a) “Brand name” has the meaning given in s. 450.12 (1) (a).
SB737,,3131(b) “Brand name drug” means any of the following:
SB737,,32321. A prescription drug that contains a brand name and that has no medically appropriate generic equivalent.
SB737,,33332. A prescription drug that contains a brand name and that has a medically appropriate generic equivalent but to which the enrollee or other covered individual has obtained access through any of the following:
SB737,,3434a. Prior authorization.
SB737,,3535b. A step therapy protocol.
SB737,,3636c. The exceptions and appeals process of the disability insurance policy, self-insured health plan, or pharmacy benefit manager.
SB737,,3737(c) “Cost-sharing requirement” means a deductible, copayment, or coinsurance.
SB737,,3838(d) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
SB737,,3939(e) “Generic equivalent” means a drug product equivalent, as defined in s. 450.13 (1e), that is nationally available.
SB737,,4040(f) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
SB737,,4141(g) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
SB737,,4242(2) Application of payments. Except as provided in sub. (4), a disability insurance policy that offers a prescription drug benefit, a self-insured health plan, or a pharmacy benefit manager acting on behalf of a disability insurance policy or self-insured health plan shall apply to any cost-sharing requirement or to any calculation of an out-of-pocket maximum amount of the disability insurance policy or self-insured health plan, including the annual limitations on cost sharing established under 42 USC 18022 (c) and 42 USC 300gg-6 (b), any amounts paid by an enrollee or other individual covered under the disability insurance policy or self-insured health plan, or by any person on behalf of the enrollee or individual, for brand name drugs that are covered under the disability insurance policy or self-insured health plan.
SB737,,4343(3) Calculation of cost-sharing annual limitations. For purposes of calculating an enrollee’s contribution to the annual limitation on cost sharing under 42 USC 18022 (c) and 42 USC 300gg-6 (b), a disability insurance policy that offers a prescription drug benefit, a self-insured health plan, or a pharmacy benefit manager acting on behalf of a disability insurance policy or self-insured health plan shall include expenditures for any item or service covered under the disability insurance policy or self-insured health plan if the item or service is included within a category of essential health benefits, as described in 42 USC 18022 (b) (1), and regardless of whether the disability insurance policy, self-insured health plan, or pharmacy benefit manager classifies the item or service as an essential health benefit.
SB737,,4444(4) Exception; high deductible health plans. If applying the requirement under sub. (2) to payments made by or on behalf of an enrollee or other individual covered under a high deductible health plan, as defined under 26 USC 223 (c) (2), would result in the enrollee failing to meet the definition of an eligible individual under 26 USC 223 (c) (1), the disability insurance policy, self-insured health plan, or pharmacy benefit manager shall begin applying the requirement under sub. (2) to the disability insurance policy or self-insured health plan’s deductible after the enrollee has satisfied the minimum deductible requirement under 26 USC 223 (c) (2) (A) (i). This subsection does not apply to any amounts paid for items or services that are preventive care, as described in 26 USC 223 (c) (2) (C).