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632.85 632.85 Coverage without prior authorization for treatment of an emergency medical condition.
632.85(1)(1)In this section:
632.85(1)(a) (a) “Emergency medical condition" means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, to lead a prudent layperson who possesses an average knowledge of health and medicine to reasonably conclude that a lack of immediate medical attention will likely result in any of the following:
632.85(1)(a)1. 1. Serious jeopardy to the person's health or, with respect to a pregnant woman, serious jeopardy to the health of the woman or her unborn child.
632.85(1)(a)2. 2. Serious impairment to the person's bodily functions.
632.85(1)(a)3. 3. Serious dysfunction of one or more of the person's body organs or parts.
632.85(1)(b) (b) “Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
632.85(1)(c) (c) “Self-insured health plan" means a self-insured health plan of the state or a county, city, village, town or school district.
632.85(2) (2)If a health care plan or a self-insured health plan provides coverage of any emergency medical services, the health care plan or self-insured health plan shall provide coverage of emergency medical services that are provided in a hospital emergency facility and that are needed to evaluate or stabilize, as defined in section 1867 of the federal Social Security Act, an emergency medical condition.
632.85(3) (3)A health care plan or a self-insured health plan that is required to provide the coverage under sub. (2) may not require prior authorization for the provision or coverage of the emergency medical services specified in sub. (2).
632.85 History History: 1997 a. 155.
632.853 632.853 Coverage of drugs and devices. A health care plan, as defined in s. 628.36 (2) (a) 1., or a self-insured health plan, as defined in s. 632.85 (1) (c), that provides coverage of only certain specified prescription drugs or devices shall develop a process through which a physician may present medical evidence to obtain an individual patient exception for coverage of a prescription drug or device not routinely covered by the plan. The process shall include timelines for both urgent and nonurgent review.
632.853 History History: 1997 a. 237.
632.855 632.855 Requirements if experimental treatment limited.
632.855(1)(1)Definitions. In this section:
632.855(1)(a) (a) “Health care plan" has the meaning given in s. 628.36 (2) (a) 1.
632.855(1)(b) (b) “Self-insured health plan" has the meaning given in s. 632.85 (1) (c).
632.855(2) (2) Disclosure of limitations. Subject to s. 632.87 (6), a health care plan or a self-insured health plan that limits coverage of experimental treatment shall define the limitation and disclose the limits in any agreement, policy or certificate of coverage. This disclosure shall include the following information:
632.855(2)(a) (a) Who is authorized to make a determination on the limitation.
632.855(2)(b) (b) The criteria the plan uses to determine whether a treatment, procedure, drug or device is experimental.
632.855(3) (3) Denial of treatment.
632.855(3)(am)(am) A health care plan or a self-insured health plan that receives a request for prior authorization of an experimental procedure that includes all of the required information upon which to make a decision shall, within 5 working days after receiving the request, issue a coverage decision. If the health care plan or self-insured health plan denies coverage of an experimental treatment, procedure, drug or device for an insured who has a terminal condition or illness, the health care plan or self-insured health plan shall, as part of its coverage decision, provide the insured with a denial letter that includes all of the following:
632.855(3)(am)1. 1. A statement setting forth the specific medical and scientific reasons for denying coverage.
632.855(3)(am)2. 2. Notice of the insured's right to appeal and a description of the appeal procedure.
632.855(3)(bm) (bm) A health care plan or a self-insured health plan may not deny coverage under par. (am) of an experimental treatment, procedure, drug, or device for an insured if the denial violates s. 632.87 (6).
632.855 History History: 1997 a. 237; 2005 a. 194.
632.857 632.857 Explanation required for restriction or termination of coverage. If an insurer restricts or terminates an insured's coverage for the treatment of a condition or complaint and, as a result, the insured becomes liable for payment for all of his or her treatment for the condition or complaint, the insurer shall provide on the explanation of benefits form a detailed explanation of the clinical rationale and of the basis in the policy, plan, or contract or in applicable law for the insurer's restriction or termination of coverage.
632.857 History History: 2007 a. 20.
632.86 632.86 Restrictions on pharmaceutical services.
632.86(1)(1)In this section:
632.86(1)(a) (a) “Disability insurance policy" has the meaning given in s. 632.895 (1) (a), except that the term does not include coverage under a health maintenance organization, as defined in s. 609.01 (2), a limited service health organization, as defined in s. 609.01 (3), a preferred provider plan, as defined in s. 609.01 (4), or a health care plan operated by a cooperative association organized under s. 185.981.
632.86(1)(b) (b) “Pharmaceutical mail order plan" means a plan under which prescribed drugs or devices are dispensed through the mail.
632.86(1)(c) (c) “Prescribed drug or device" has the meaning given in s. 450.01 (18).
632.86(2) (2)No group or blanket disability insurance policy that provides coverage of prescribed drugs or devices through a pharmaceutical mail order plan may do any of the following:
632.86(2)(a) (a) Exclude coverage, expressly or by implication, of any prescribed drug or device provided by a pharmacist or pharmacy selected by a covered individual if the pharmacist or pharmacy provides or agrees to provide prescribed drugs or devices under the terms of the policy and at the same cost to the insurer issuing the policy as a pharmaceutical mail order plan.
632.86(2)(b) (b) Contain coverage, deductible or copayment provisions for prescribed drugs or devices provided by a pharmacist or pharmacy selected by a covered individual that are different from the coverage, deductible or copayment provisions for prescribed drugs or devices provided by a pharmaceutical mail order plan.
Effective date note NOTE: This section is repealed eff. 1-1-22 by 2021 Wis. Act 9.
632.86 History History: 1991 a. 70; 2009 a. 165; 2021 a. 9.
632.861 632.861 Prescription drug charges.
632.861(1)(1)Definitions. In this section:
632.861(1)(a) (a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
632.861(1)(b) (b) “Enrollee” means an individual who is covered under a disability insurance policy or a self-insured health plan.
632.861(1)(c) (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
632.861(1)(d) (d) “Prescription drug” has the meaning given in s. 450.01 (20).
632.861(1)(e) (e) “Prescription drug benefit” has the meaning given in s. 632.865 (1) (e).
632.861(1)(f) (f) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
Effective date note NOTE: Section 632.861 (title) and (1) are created eff. 1-1-22 by 2021 Wis. Act 9, sections 15 and 46m (intro.).
632.861(2) (2) Allowing disclosures.
632.861(2)(a)(a) A disability insurance policy or self-insured health plan that provides a prescription drug benefit may not restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.
632.861(2)(b) (b) A disability insurance policy or self-insured health plan that provides a prescription drug benefit shall ensure that any pharmacy benefit manager that provides services under a contract with the policy or plan does not, with respect to such policy or plan, restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.
632.861(3) (3) Cost-sharing limitation. A disability insurance policy or self-insured health plan that provides a prescription drug benefit or a pharmacy benefit manager that provides services under a contract with a policy or plan may not require an enrollee to pay at the point of sale for a covered prescription drug an amount that is greater than the lowest of all of the following amounts:
632.861(3)(a) (a) The cost-sharing amount for the prescription drug for the enrollee under the policy or plan.
632.861(3)(b) (b) The amount a person would pay for the prescription drug if the enrollee purchased the prescription drug at the dispensing pharmacy without using any health plan or health insurance coverage.
Effective date note NOTE: Sub. (3) is created eff. 6-30-21 by 2021 Wis. Act 9, sections 15 and 46m (2).
632.861(4) (4) Drug substitution.
632.861(4)(a)(a) Except as provided in par. (b), 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 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.
632.861(4)(b)1.1. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if the prescription drug that is to be removed or reassigned is any of the following:
632.861(4)(b)1.a. a. No longer approved by the federal food and drug administration.
632.861(4)(b)1.b. b. The subject of a notice, guidance, warning, announcement, or other statement from the federal food and drug administration relating to concerns about the safety of the prescription drug.
632.861(4)(b)1.c. c. Approved by the federal food and drug administration for use without a prescription.
632.861(4)(b)2. 2. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if, for the prescription drug that is being removed from the formulary or reassigned to a benefit tier that has a higher deductible, copayment, or coinsurance, the policy, plan, or pharmacy benefit manager adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:
632.861(4)(b)2.a. a. The same benefit tier from which the prescription drug is being removed or reassigned.
632.861(4)(b)2.b. b. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.
632.861(4)(c) (c) A pharmacist or pharmacy shall notify an enrollee in a disability insurance policy or self-insured health plan if a prescription drug for which an enrollee is filling or refilling a prescription is removed from the formulary and the policy or plan or a pharmacy benefit manager acting on behalf of a policy or plan adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:
632.861(4)(c)1. 1. The same benefit tier from which the prescription drug is being removed or reassigned.
632.861(4)(c)2. 2. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.
632.861(4)(d) (d) If an enrollee has had an adverse reaction to the generic prescription drug or the prescription drug in the same pharmacologic class or with the same mechanism of action that is being substituted for an originally prescribed drug, the pharmacist or pharmacy may extend the prescription order for the originally prescribed drug to fill one 30-day supply of the originally prescribed drug for the cost-sharing amount that applies to the prescription drug at the time of the substitution.
Effective date note NOTE: Sub. (4) is created eff. 1-1-22 by 2021 Wis. Act 9, sections 15 and 46m (intro.).
632.861 History History: 2021 a. 9.
632.865 632.865 Pharmacy benefit managers.
632.865(1)(1)Definitions. In this section:
632.865(1)(a) (a) “Pharmacist" has the meaning given in s. 450.01 (15).
Effective date note NOTE: Par. (a) is renumbered to par. (aw) eff. 1-1-22 by 2021 Wis. Act 9, sections 16 and 46m (intro.).
632.865(1)(ae) (ae) “Health benefit plan” has the meaning given in s. 632.745 (11).
Effective date note NOTE: Par. (ae) is created eff. 1-1-22 by 2021 Wis. Act 9, sections 17 and 46m (intro.).
632.865(1)(ak) (ak) “Health care provider” has the meaning given in s. 146.81 (1).
Effective date note NOTE: Par. (ak) is created eff. 1-1-22 by 2021 Wis. Act 9, sections 17 and 46m (intro.).
632.865(1)(aw) (aw) “Pharmacist" has the meaning given in s. 450.01 (15).
Effective date note NOTE: Par. (aw) is shown as renumbered from par. (a) eff. 1-1-22 by 2021 Wis. Act 9, sections 16 and 46m (intro.).
632.865(1)(b) (b) “Pharmacy" means an entity licensed under s. 450.06 or 450.065.
632.865(1)(c) (c) “Pharmacy benefit manager" means an entity doing business in this state that contracts to administer or manage prescription drug benefits on behalf of any of the following:
632.865(1)(c)1. 1. An insurer.
632.865(1)(c)2. 2. A cooperative, as defined in s. 185.01 (2).
632.865(1)(c)3. 3. Another entity that provides prescription drug benefits to residents of this state.
Effective date note NOTE: Par. (c) is shown as affected eff. 1-1-22 by 2021 Wis. Act 9, sections 18, 19, and 46m (intro.). Prior to 1-1-22 it reads:
Effective date text (c) “Pharmacy benefit manager" means an entity doing business in this state that contracts to administer or manage prescription drug benefits on behalf of any insurer or other entity that provides prescription drug benefits to residents of this state.
632.865(1)(d) (d) “Prescribed drug or device" has the meaning given in s. 450.01 (18).
632.865(1)(dm) (dm) “Prescription drug" has the meaning given in s. 450.01 (20).
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2019-20 Wisconsin Statutes updated through 2021 Wis. Act 31, through all Orders of the Controlled Substances Board filed before and in effect on June 2, 2021, and through all Supreme Court Orders filed before and in effect on April 15, 2021. Published and certified under s. 35.18. Changes effective after June 2, 2021, other than those made by Supreme Court Order No. 20-07, are designated by NOTES. (Published 6-2-21)