Wisconsin 2025-2026 Regular Session

Wisconsin Assembly Bill AB173 Compare Versions

Only one version of the bill is available at this time.

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1	1	2025 - 2026 LEGISLATURE
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4	4	2025 ASSEMBLY BILL 173
5	5	April 9, 2025 - Introduced by Representatives NOVAK, TRANEL, ALLEN, ARMSTRONG,
6	6	BROOKS, CALLAHAN, FITZGERALD, B. JACOBSON, JOERS, KIRSCH, KITCHENS,
7	7	KNODL, KREIBICH, MCCARVILLE, MIRESSE, MURSAU, O'CONNOR, SORTWELL,
8	8	TITTL, WICHGERS and TUCKER, cosponsored by Senators FELZKOWSKI,
9	9	MARKLEIN, CABRAL-GUEVARA, DASSLER-ALFHEIM, DRAKE, HABUSH SINYKIN,
10	10	L. JOHNSON, KEYESKI, LARSON, NASS, PFAFF, QUINN, RATCLIFF, ROYS,
11	11	SPREITZER, WANGGAARD, WIMBERGER and JAMES. Referred to Committee on
12	12	Health, Aging and Long-Term Care.
13	13
14	14	*AUTHORS SUBJECT TO CHANGE*
15	15	AN ACT to repeal 632.865 (2) and 632.865 (5) (e); to renumber 632.865 (4); to
16	16	amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.),
17	17	609.83, 632.861 (4) (a), 632.865 (1) (ae) and 632.865 (6) (c) 3.; to create
18	18	632.861 (1m), 632.861 (3g), 632.861 (3r), 632.861 (4) (e), 632.862, 632.865 (1)
19	19	(ab) and (ac), 632.865 (1) (an), (aq) and (at), 632.865 (1) (bm), 632.865 (1) (cg)
20	20	and (cr), 632.865 (2d), 632.865 (2h), 632.865 (2p), 632.865 (2t), 632.865 (4) (b),
21	21	632.865 (4m), 632.865 (5d), 632.865 (5h), 632.865 (5p), 632.865 (5t), 632.865
22	22	(6) (bm), 632.865 (6) (c) 3m., 632.865 (6g), 632.865 (6r) and 632.865 (8) of the
23	23	statutes; relating to: regulation of pharmacy benefit managers, fiduciary and
24	24	disclosure requirements on pharmacy benefit managers, and application of
25	25	prescription drug payments to health insurance cost-sharing requirements.
26	26	Analysis by the Legislative Reference Bureau
27	27	This bill makes several changes to the regulation of pharmacy benefit
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42	42	managers and their interactions with pharmacies and pharmacists. Under current
43	43	law, pharmacy benefit managers are generally required to be licensed as a
44	44	pharmacy benefit manager or an employee benefit plan administrator by the
45	45	commissioner of insurance. A pharmacy benefit manager is an entity that
46	46	contracts to administer or manage prescription drug benefits on behalf of an
47	47	insurer, a cooperative, or another entity that provides prescription drug benefits to
48	48	Wisconsin residents. Major provisions of the bill are summarized below.
49	49	Pharmacy benefit manager regulation
50	50	The bill requires a pharmacy benefit manager to pay a pharmacy or
51	51	pharmacist a professional dispensing fee at a rate not less than is paid by the state
52	52	under the Medical Assistance program for each pharmaceutical product that the
53	53	pharmacy or pharmacist dispenses to an individual. The professional dispensing
54	54	fee is required to be paid in addition to the amount the pharmacy benefit manager
55	55	reimburses the pharmacy or pharmacist for the cost of the pharmaceutical product
56	56	that the pharmacy or pharmacist dispenses. The Medical Assistance program is a
57	57	joint state and federal program that provides health services to individuals who
58	58	have limited financial resources.
59	59	The bill prohibits a pharmacy benefit manager from assessing, charging, or
60	60	collecting from a pharmacy or pharmacist any form of remuneration that passes
61	61	from the pharmacy or pharmacist to the pharmacy benefit manager including
62	62	claim-processing fees, performance-based fees, network-participation fees, or
63	63	accreditation fees.
64	64	Further, under the bill, a pharmacy benefit manager may not use any
65	65	certification or accreditation requirement as a determinant of pharmacy network
66	66	participation that is inconsistent with, more stringent than, or in addition to the
67	67	federal requirements for licensure as a pharmacy and the requirements for
68	68	licensure as a pharmacy provided under state law.
69	69	The bill requires a pharmacy benefit manager to allow a participant or
70	70	beneficiary of a pharmacy benefits plan or program that the pharmacy benefit
71	71	manager serves to use any pharmacy or pharmacist in this state that is licensed to
72	72	dispense the pharmaceutical product that the participant or beneficiary seeks to
73	73	obtain if the pharmacy or pharmacist accepts the same terms and conditions that
74	74	the pharmacy benefit manager establishes for at least one of the networks of
75	75	pharmacies or pharmacists that the pharmacy benefit manager has established to
76	76	serve individuals in the state. A pharmacy benefit manager may establish a
77	77	preferred network of pharmacies or pharmacists and a nonpreferred network of
78	78	pharmacies or pharmacists; however, under the bill, a pharmacy benefit manager
79	79	may not prohibit a pharmacy or pharmacist from participating in either type of
80	80	network provided that the pharmacy or pharmacist is licensed by this state and the
81	81	federal government and accepts the same terms and conditions that the pharmacy
82	82	benefit manager establishes for other pharmacies or pharmacists participating in
83	83	the network that the pharmacy or pharmacist wants to join. Under the bill, a
84	84	pharmacy benefit manager may not charge a participant or beneficiary of a 2025 - 2026 Legislature
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88	88	pharmacy benefits plan or program that the pharmacy benefit manager serves a
89	89	different copayment obligation or additional fee, or provide any inducement or
90	90	financial incentive, for the participant or beneficiary to use a pharmacy or
91	91	pharmacist in a particular network of pharmacies or pharmacists that the
92	92	pharmacy benefit manager has established to serve individuals in the state.
93	93	Further, the bill prohibits a pharmacy benefit manager, third-party payer, or health
94	94	benefit plan from excluding a pharmacy or pharmacist from its network because the
95	95	pharmacy or pharmacist serves less than a certain portion of the population of the
96	96	state or serves a population living with certain health conditions.
97	97	The bill provides that a pharmacy benefit manager may neither prohibit a
98	98	pharmacy or pharmacist that dispenses a pharmaceutical product from, nor
99	99	penalize a pharmacy or pharmacist that dispenses a pharmaceutical product for,
100	100	informing an individual about the cost of the pharmaceutical product, the amount
101	101	in reimbursement that the pharmacy or pharmacist receives for dispensing the
102	102	pharmaceutical product, or any difference between the cost to the individual under
103	103	the individual[s pharmacy benefits plan or program and the cost to the individual if
104	104	the individual purchases the pharmaceutical product without making a claim for
105	105	benefits under the individual[s pharmacy benefits plan or program.
106	106	The bill prohibits any pharmacy benefit manager or any insurer or self-
107	107	insured health plan from requiring, or penalizing a person who is covered under a
108	108	health insurance policy or plan for using or for not using, a specific retail, mail-
109	109	order, or other pharmacy provider within the network of pharmacy providers under
110	110	the policy or plan. Prohibited penalties include an increase in premium, deductible,
111	111	copayment, or coinsurance.
112	112	The bill requires pharmacy benefit managers to remit payment for a claim to
113	113	a pharmacy or pharmacist within 30 days from the day that the claim is submitted
114	114	to the pharmacy benefit manager by the pharmacy or pharmacist.
115	115	Pharmaceutical product reimbursements
116	116	The bill provides that a pharmacy benefit manager that uses a maximum
117	117	allowable cost list must include all of the following information on the list: 1) the
118	118	average acquisition cost of each pharmaceutical product and the cost of the
119	119	pharmaceutical product set forth in the national average drug acquisition cost data
120	120	published by the federal centers for medicare and medicaid services; 2) the average
121	121	manufacturer price of each pharmaceutical product; 3) the average wholesale price
122	122	of each pharmaceutical product; 4) the brand effective rate or generic effective rate
123	123	for each pharmaceutical product; 5) any applicable discount indexing; 6) the federal
124	124	upper limit for each pharmaceutical product published by the federal centers for
125	125	medicare and medicaid services; 7) the wholesale acquisition cost of each
126	126	pharmaceutical product; and 8) any other terms that are used to establish the
127	127	maximum allowable costs.
128	128	The bill provides that a pharmacy benefit manager may place or continue a
129	129	particular pharmaceutical product on a maximum allowable cost list only if the
130	130	pharmaceutical product 1) is listed as a drug product equivalent or is rated by a 2025 - 2026 Legislature
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134	134	nationally recognized reference as Xnot ratedY or Xnot availableY; 2) is available for
135	135	purchase by all pharmacies and pharmacists in the state from national or regional
136	136	pharmaceutical wholesalers operating in the state; and 3) has not been determined
137	137	by the drug manufacturer to be obsolete. Further, the bill provides that any
138	138	pharmacy benefit manager that uses a maximum allowable cost list must provide
139	139	access to the maximum allowable cost list to each pharmacy or pharmacist subject
140	140	to the maximum allowable cost list, update the maximum allowable cost list on a
141	141	timely basis, provide a process for a pharmacy or pharmacist subject to the
142	142	maximum allowable cost list to receive notification of an update to the maximum
143	143	allowable cost list, and update the maximum allowable cost list no later than seven
144	144	days after the pharmacy acquisition cost of the pharmaceutical product increases
145	145	by 10 percent or more from at least 60 percent of the pharmaceutical wholesalers
146	146	doing business in the state or there is a change in the methodology on which the
147	147	maximum allowable cost list is based or in the value of a variable involved in the
148	148	methodology. A maximum allowable cost list is a list of pharmaceutical products
149	149	that sets forth the maximum amount that a pharmacy benefit manager will pay to
150	150	a pharmacy or pharmacist for dispensing a pharmaceutical product. A maximum
151	151	allowable cost list may directly establish maximum costs or may set forth a method
152	152	for how the maximum costs are calculated.
153	153	The bill further provides that a pharmacy benefit manager that uses a
154	154	maximum allowable cost list must provide a process for a pharmacy or pharmacist
155	155	to appeal and resolve disputes regarding claims that the maximum payment
156	156	amount for a pharmaceutical product is below the pharmacy acquisition cost. A
157	157	pharmacy benefit manager that receives an appeal from or on behalf of a pharmacy
158	158	or pharmacist under this bill is required to resolve the appeal and notify the
159	159	pharmacy or pharmacist of the pharmacy benefit manager[s determination no later
160	160	than seven business days after the appeal is received. If the pharmacy benefit
161	161	manager grants the relief requested in the appeal, the bill requires the pharmacy
162	162	benefit manager to make the requested change in the maximum allowable cost,
163	163	allow the pharmacy or pharmacist to reverse and rebill the relevant claim, provide
164	164	to the pharmacy or pharmacist the national drug code number published in a
165	165	directory by the federal Food and Drug Administration on which the increase or
166	166	change is based, and make the change effective for each similarly situated
167	167	pharmacy or pharmacist subject to the maximum allowable cost list. If the
168	168	pharmacy benefit manager denies the relief requested in the appeal, the bill
169	169	requires the pharmacy benefit manager to provide the pharmacy or pharmacist a
170	170	reason for the denial, the national drug code number published in a directory by the
171	171	FDA for the pharmaceutical product to which the claim relates, and the name of a
172	172	national or regional wholesaler that has the pharmaceutical product currently in
173	173	stock at a price below the amount specified in the pharmacy benefit manager[s
174	174	maximum allowable cost list.
175	175	The bill provides that a pharmacy benefit manager may not deny a
176	176	pharmacy[s or pharmacist[s appeal if the relief requested in the appeal relates to 2025 - 2026 Legislature
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180	180	the maximum allowable cost for a pharmaceutical product that is not available for
181	181	the pharmacy or pharmacist to purchase at a cost that is below the pharmacy
182	182	acquisition cost from the pharmaceutical wholesaler from which the pharmacy or
183	183	pharmacist purchases the majority of pharmaceutical products for resale. If a
184	184	pharmaceutical product is not available for a pharmacy or pharmacist to purchase
185	185	at a cost that is below the pharmacy acquisition cost from the pharmaceutical
186	186	wholesaler from which the pharmacy or pharmacist purchases the majority of
187	187	pharmaceutical products for resale, the pharmacy benefit manager must revise the
188	188	maximum allowable cost list to increase the maximum allowable cost for the
189	189	pharmaceutical product to an amount equal to or greater than the pharmacy[s or
190	190	pharmacist[s pharmacy acquisition cost and allow the pharmacy or pharmacist to
191	191	reverse and rebill each claim affected by the pharmacy[s or pharmacist[s inability to
192	192	procure the pharmaceutical product at a cost that is equal to or less than the
193	193	maximum allowable cost that was the subject of the pharmacy[s or pharmacist[s
194	194	appeal.
195	195	The bill prohibits a pharmacy benefit manager from reimbursing a pharmacy
196	196	or pharmacist in the state an amount less than the amount that the pharmacy
197	197	benefit manager reimburses a pharmacy benefit manager affiliate for providing the
198	198	same pharmaceutical product. Under the bill, a pharmacy benefit manager
199	199	affiliate is a pharmacy or pharmacist that is an affiliate of a pharmacy benefit
200	200	manager.
201	201	Finally, the bill allows a pharmacy or pharmacist to decline to provide a
202	202	pharmaceutical product to an individual or pharmacy benefit manager if, as a
203	203	result of a maximum allowable cost list, the pharmacy or pharmacist would be paid
204	204	less than the pharmacy acquisition cost of the pharmacy or pharmacist providing
205	205	the pharmaceutical product.
206	206	Drug formularies
207	207	This bill makes several changes with respect to drug formularies. Under
208	208	current law, a disability insurance policy that offers a prescription drug benefit, a
209	209	self-insured health plan that offers a prescription drug benefit, or a pharmacy
210	210	benefit manager acting on behalf of a disability insurance policy or self-insured
211	211	health plan must provide to an enrollee advanced written notice of a formulary
212	212	change that removes a prescription drug from the formulary of the policy or plan or
213	213	that reassigns a prescription drug to a benefit tier for the policy or plan that has a
214	214	higher deductible, copayment, or coinsurance. The advanced written notice of a
215	215	formulary change must be provided no fewer than 30 days before the expected date
216	216	of the removal or reassignment.
217	217	This bill provides that a disability insurance policy or self-insured health plan
218	218	that provides a prescription drug benefit shall make the formulary and all drug
219	219	costs associated with the formulary available to plan sponsors and individuals prior
220	220	to selection or enrollment. Further, the bill provides that no disability insurance
221	221	policy, self-insured health plan, or pharmacy benefit manager acting on behalf of a
222	222	disability insurance policy or self-insured health plan may remove a prescription 2025 - 2026 Legislature
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226	226	drug from the formulary except at the time of coverage renewal. Finally, the bill
227	227	provides that advanced written notice of a formulary change must be provided no
228	228	fewer than 90 days before the expected date of the removal or reassignment of a
229	229	prescription drug on the formulary.
230	230	Pharmacy networks
231	231	Under the bill, if an enrollee utilizes a pharmacy or pharmacist in a preferred
232	232	network of pharmacies or pharmacists, no disability insurance policy or self-
233	233	insured health plan that provides a prescription drug benefit or pharmacy benefit
234	234	manager that provides services under a contract with a policy or plan may require
235	235	the enrollee to pay any amount or impose on the enrollee any condition that would
236	236	not be required if the enrollee utilized a different pharmacy or pharmacist in the
237	237	same preferred network. Further, the bill provides that any disability insurance
238	238	policy or self-insured health plan that provides a prescription drug benefit, or any
239	239	pharmacy benefit manager that provides services under a contract with a policy or
240	240	plan, that has established a preferred network of pharmacies or pharmacists must
241	241	reimburse each pharmacy or pharmacist in the same network at the same rates.
242	242	Audits of pharmacists and pharmacies
243	243	This bill makes several changes to audits of pharmacists and pharmacies. The
244	244	bill requires an entity that conducts audits of pharmacists and pharmacies to
245	245	ensure that each pharmacist or pharmacy audited by the entity is audited under
246	246	the same standards and parameters as other similarly situated pharmacists or
247	247	pharmacies audited by the entity, that the entity randomizes the prescriptions that
248	248	the entity audits and the entity audits the same number of prescriptions in each
249	249	prescription benefit tier, and that each audit of a prescription reimbursed under
250	250	Part D of the federal Medicare program is conducted separately from audits of
251	251	prescriptions reimbursed under other policies or plans. The bill prohibits any
252	252	pharmacy benefit manager from recouping reimbursements made to a pharmacist
253	253	or pharmacy for errors that involve no actual financial harm to an enrollee or a
254	254	policy or plan sponsor unless the error is the result of the pharmacist or pharmacy
255	255	failing to comply with a formal corrective action plan. The bill further prohibits any
256	256	pharmacy benefit manager from using extrapolation in calculating reimbursements
257	257	that it may recoup, and instead requires a pharmacy benefit manager to base the
258	258	finding of errors for which reimbursements will be recouped on an actual error in
259	259	reimbursement and not a projection of the number of patients served having a
260	260	similar diagnosis or on a projection of the number of similar orders or refills for
261	261	similar prescription drugs. The bill provides that a pharmacy benefit manager that
262	262	recoups any reimbursements made to a pharmacist or pharmacy for an error that
263	263	was the cause of financial harm must return the recouped reimbursement to the
264	264	enrollee or the policy or plan sponsor who was harmed by the error.
265	265	Pharmacy benefit manager fiduciary and disclosure requirements
266	266	The bill provides that a pharmacy benefit manager owes a fiduciary duty to a
267	267	health benefit plan sponsor. The bill also requires that a pharmacy benefit 2025 - 2026 Legislature
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271	271	manager annually disclose all of the following information to the health benefit
272	272	plan sponsor:
273	273	1. The indirect profit received by the pharmacy benefit manager from owning
274	274	a pharmacy or health service provider.
275	275	2. Any payments made to a consultant or broker who works on behalf of the
276	276	plan sponsor.
277	277	3. From the amounts received from drug manufacturers, the amounts
278	278	retained by the pharmacy benefit manager that are related to the plan sponsor[s
279	279	claims or bona fide service fees.
280	280	4. The amounts received from network pharmacies and pharmacists and the
281	281	amount retained by the pharmacy benefit manager.
282	282	Discriminatory reimbursement of 340B entities
283	283	The bill prohibits a pharmacy benefit manager from taking certain actions
284	284	with respect to 340B covered entities, pharmacies and pharmacists contracted with
285	285	340B covered entities, and patients who obtain prescription drugs from 340B
286	286	covered entities. The 340B drug pricing program is a federal program that requires
287	287	pharmaceutical manufacturers that participate in the federal Medicaid program to
288	288	sell outpatient drugs at discounted prices to certain health care organizations that
289	289	provide health care for uninsured and low-income patients. Entities that are
290	290	eligible for discounted prices under the 340B drug pricing program include
291	291	federally qualified health centers, critical access hospitals, and certain public and
292	292	nonprofit disproportionate share hospitals. The bill prohibits pharmacy benefit
293	293	managers from doing any of the following:
294	294	1. Refusing to reimburse a 340B covered entity or a pharmacy or pharmacist
295	295	contracted with a 340B covered entity for dispensing 340B drugs.
296	296	2. Imposing requirements or restrictions on 340B covered entities or
297	297	pharmacies or pharmacists contracted with 340B covered entities that are not
298	298	imposed on other entities, pharmacies, or pharmacists.
299	299	3. Reimbursing a 340B covered entity or a pharmacy or pharmacist
300	300	contracted with a 340B covered entity for a 340B drug at a rate lower than the
301	301	amount paid for the same drug to pharmacies or pharmacists that are not 340B
302	302	covered entities or pharmacies or pharmacists contracted with a 340B covered
303	303	entity.
304	304	4. Assessing a fee, charge back, or other adjustment against a 340B covered
305	305	entity or a pharmacy or pharmacist contracted with a 340B covered entity after a
306	306	claim has been paid or adjudicated.
307	307	5. Restricting the access of a 340B covered entity or a pharmacy or
308	308	pharmacist contracted with a 340B covered entity to a third-party payer[s
309	309	pharmacy network solely because the 340B covered entity or the pharmacy or
310	310	pharmacist contracted with a 340B covered entity participates in the 340B drug
311	311	pricing program.
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316	316	with a 340B covered entity to contract with a specific pharmacy or pharmacist or
317	317	health benefit plan in order to access a third-party payer[s pharmacy network.
318	318	7. Imposing a restriction or an additional charge on a patient who obtains a
319	319	340B drug from a 340B covered entity or a pharmacy or pharmacist contracted with
320	320	a 340B covered entity.
321	321	8. Restricting the methods by which a 340B covered entity or a pharmacy or
322	322	pharmacist contracted with a 340B covered entity may dispense or deliver 340B
323	323	drugs.
324	324	9. Requiring a 340B covered entity or a pharmacy or pharmacist contracted
325	325	with a 340B covered entity to share pharmacy bills or invoices with a pharmacy
326	326	benefit manager, a third-party payer, or a health benefit plan.
327	327	Application of prescription drug payments
328	328	Health insurance policies and plans often apply cost-sharing requirements
329	329	and out-of-pocket maximum amounts to the benefits covered by the policy or plan.
330	330	A cost-sharing requirement is a share of covered benefits that an insured is
331	331	required to pay under a health insurance policy or plan. Cost-sharing requirements
332	332	include copayments, deductibles, and coinsurance. An out-of-pocket maximum
333	333	amount is a limit specified by a policy or plan on the amount that an insured pays,
334	334	and, once that limit is reached, the policy or plan covers the benefit entirely. The
335	335	bill generally requires health insurance policies that offer prescription drug
336	336	benefits, self-insured health plans, and pharmacy benefit managers acting on
337	337	behalf of policies or plans to apply amounts paid by or on behalf of an individual
338	338	covered under the policy or plan for brand name prescription drugs to any cost-
339	339	sharing requirement or to any calculation of an out-of-pocket maximum amount of
340	340	the policy or plan. Health insurance policies are referred to in the bill as disability
341	341	insurance policies.
342	342	Prohibited retaliation
343	343	The bill prohibits a pharmacy benefit manager from retaliating against a
344	344	pharmacy or pharmacist for reporting an alleged violation of certain laws
345	345	applicable to pharmacy benefit managers or for exercising certain rights or
346	346	remedies. Retaliation includes terminating or refusing to renew a contract with a
347	347	pharmacy or pharmacist, subjecting a pharmacy or pharmacist to increased audits,
348	348	or failing to promptly pay a pharmacy or pharmacist any money that the pharmacy
349	349	benefit manager owes to the pharmacy or pharmacist. The bill provides that a
350	350	pharmacy or pharmacist may bring an action in court for injunctive relief if a
351	351	pharmacy benefit manager is retaliating against the pharmacy or pharmacist as
352	352	provided in the bill. In addition to equitable relief, the court may award a pharmacy
353	353	or pharmacist that prevails in such an action reasonable attorney fees and costs.
354	354	For further information see the state fiscal estimate, which will be printed as
355	355	an appendix to this bill. 2025 - 2026 Legislature
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359	359	SECTION 1
360	360	The people of the state of Wisconsin, represented in senate and assembly, do
361	361	enact as follows:
362	362	SECTION 1. 40.51 (8) of the statutes is amended to read:
363	363	40.51 (8) Every health care coverage plan offered by the state under sub. (6)
364	364	shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.722,
365	365	632.729, 632.746 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835,
366	366	632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (3) to (6), 632.885,
367	367	632.89, 632.895 (5m) and (8) to (17), and 632.896.
368	368	SECTION 2. 40.51 (8m) of the statutes is amended to read:
369	369	40.51 (8m) Every health care coverage plan offered by the group insurance
370	370	board under sub. (7) shall comply with ss. 631.95, 632.722, 632.729, 632.746 (1) to
371	371	(8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855,
372	372	632.861, 632.862, 632.867, 632.885, 632.89, and 632.895 (11) to (17).
373	373	SECTION 3. 66.0137 (4) of the statutes is amended to read:
374	374	66.0137 (4) SELF-INSURED HEALTH PLANS. If a city, including a 1st class city,
375	375	or a village provides health care benefits under its home rule power, or if a town
376	376	provides health care benefits, to its officers and employees on a self-insured basis,
377	377	the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
378	378	632.722, 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85,
379	379	632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4) to (6), 632.885, 632.89,
380	380	632.895 (9) to (17), 632.896, and 767.513 (4).
381	381	SECTION 4. 120.13 (2) (g) of the statutes is amended to read:
382	382	120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
383	383	49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.722, 632.729, 632.746 (10) (a) 2. and
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408	408	JPC:cjs&skw
409	409	SECTION 4
410	410	(b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867,
411	411	632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
412	412	SECTION 5. 185.983 (1) (intro.) of the statutes is amended to read:
413	413	185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
414	414	cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
415	415	646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
416	416	601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
417	417	631.95, 632.72 (2), 632.722, 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795,
418	418	632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (2) to (6),
419	419	632.885, 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609,
420	420	620, 630, 635, 645, and 646, but the sponsoring association shall:
421	421	SECTION 6. 609.83 of the statutes is amended to read:
422	422	609.83 Coverage of drugs and devices; application of payments.
423	423	Limited service health organizations, preferred provider plans, and defined
424	424	network plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and
425	425	(16v).
426	426	SECTION 7. 632.861 (1m) of the statutes is created to read:
427	427	632.861 (1m) REQUIRED DISCLOSURES. A disability insurance policy or self-
428	428	insured health plan that provides a prescription drug benefit shall make the
429	429	formulary and all drug costs associated with the formulary available to plan
430	430	sponsors and individuals prior to selection or enrollment.
431	431	SECTION 8. 632.861 (3g) of the statutes is created to read:
432	432	632.861 (3g) CHOICE OF PROVIDER; PENALTY PROHIBITED. No insurer, self-
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458	458	JPC:cjs&skw
459	459	SECTION 8
460	460	insured health plan, or pharmacy benefit manager may require, or penalize a
461	461	person who is covered under a disability insurance policy or self-insured health
462	462	plan for using or for not using, a specific retail, specific mail-order, or other specific
463	463	pharmacy provider within the network of pharmacy providers under the policy or
464	464	plan. A prohibited penalty under this subsection includes an increase in premium,
465	465	deductible, copayment, or coinsurance.
466	466	SECTION 9. 632.861 (3r) of the statutes is created to read:
467	467	632.861 (3r) PHARMACY NETWORKS. (a) If an enrollee utilizes a pharmacy or
468	468	pharmacist in a preferred network of pharmacies or pharmacists, no disability
469	469	insurance policy or self-insured health plan that provides a prescription drug
470	470	benefit or pharmacy benefit manager that provides services under a contract with
471	471	a policy or plan may require the enrollee to pay any amount or impose on the
472	472	enrollee any condition that would not be required if the enrollee utilized a different
473	473	pharmacy or pharmacist in the same preferred network.
474	474	(b) Any disability insurance policy or self-insured health plan that provides a
475	475	prescription drug benefit, or any pharmacy benefit manager that provides services
476	476	under a contract with a policy or plan, that has established a preferred network of
477	477	pharmacies or pharmacists shall reimburse each pharmacy or pharmacist in the
478	478	same network at the same rates.
479	479	SECTION 10. 632.861 (4) (a) of the statutes is amended to read:
480	480	632.861 (4) (a) Except as provided in par. (b) and subject to par. (e), a
481	481	disability insurance policy that offers a prescription drug benefit, a self-insured
482	482	health plan that offers a prescription drug benefit, or a pharmacy benefit manager
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508	508	JPC:cjs&skw
509	509	SECTION 10
510	510	acting on behalf of a disability insurance policy or self-insured health plan shall
511	511	provide to an enrollee advanced written notice of a formulary change that removes
512	512	a prescription drug from the formulary of the policy or plan or that reassigns a
513	513	prescription drug to a benefit tier for the policy or plan that has a higher deductible,
514	514	copayment, or coinsurance. The advanced written notice of a formulary change
515	515	under this paragraph shall be provided no fewer than 30 90 days before the
516	516	expected date of the removal or reassignment and shall include information on the
517	517	procedure for the enrollee to request an exception to the formulary change. The
518	518	policy, plan, or pharmacy benefit manager is required to provide the advanced
519	519	written notice under this paragraph only to those enrollees in the policy or plan
520	520	who are using the drug at the time the notification must be sent according to
521	521	available claims history.
522	522	SECTION 11. 632.861 (4) (e) of the statutes is created to read:
523	523	632.861 (4) (e) No disability insurance policy, self-insured health plan, or
524	524	pharmacy benefit manager acting on behalf of a disability insurance policy or self-
525	525	insured health plan may remove a prescription drug from the formulary except at
526	526	the time of coverage renewal.
527	527	SECTION 12. 632.862 of the statutes is created to read:
528	528	632.862 Application of prescription drug payments. (1) DEFINITIONS.
529	529	In this section:
530	530	(a) XBrand nameY has the meaning given in s. 450.12 (1) (a).
531	531	(b) XBrand name drugY means any of the following:
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556	556	JPC:cjs&skw
557	557	SECTION 12
558	558	1. A prescription drug that contains a brand name and that has no medically
559	559	appropriate generic equivalent.
560	560	2. A prescription drug that contains a brand name and that has a medically
561	561	appropriate generic equivalent but to which the enrollee or other covered individual
562	562	has obtained access through any of the following:
563	563	a. Prior authorization.
564	564	b. A step therapy protocol.
565	565	c. The exceptions and appeals process of the disability insurance policy, self-
566	566	insured health plan, or pharmacy benefit manager.
567	567	(c) XCost-sharing requirementY means a deductible, copayment, or
568	568	coinsurance.
569	569	(d) XDisability insurance policyY has the meaning given in s. 632.895 (1) (a).
570	570	(e) XGeneric equivalentY means a drug product equivalent, as defined in s.
571	571	450.13 (1e), that is nationally available.
572	572	(f) XPharmacy benefit managerY has the meaning given in s. 632.865 (1) (c).
573	573	(g) XSelf-insured health planY has the meaning given in s. 632.85 (1) (c).
574	574	(2) APPLICATION OF PAYMENTS. Except as provided in sub. (4), a disability
575	575	insurance policy that offers a prescription drug benefit, a self-insured health plan,
576	576	or a pharmacy benefit manager acting on behalf of a disability insurance policy or
577	577	self-insured health plan shall apply to any cost-sharing requirement or to any
578	578	calculation of an out-of-pocket maximum amount of the disability insurance policy
579	579	or self-insured health plan, including the annual limitations on cost sharing
580	580	established under 42 USC 18022 (c) and 42 USC 300gg-6 (b), any amounts paid by
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606	606	JPC:cjs&skw
607	607	SECTION 12
608	608	an enrollee or other individual covered under the disability insurance policy or self-
609	609	insured health plan, or by any person on behalf of the enrollee or individual, for
610	610	brand name drugs that are covered under the disability insurance policy or self-
611	611	insured health plan.
612	612	(3) CALCULATION OF COST-SHARING ANNUAL LIMITATIONS. For purposes of
613	613	calculating an enrollee[s contribution to the annual limitations on cost sharing
614	614	under 42 USC 18022 (c) and 42 USC 300gg-6 (b), a disability insurance policy that
615	615	offers a prescription drug benefit, a self-insured health plan, or a pharmacy benefit
616	616	manager acting on behalf of a disability insurance policy or self-insured health plan
617	617	shall include expenditures for any item or service covered under the disability
618	618	insurance policy or self-insured health plan if the item or service is included within
619	619	a category of essential health benefits, as described in 42 USC 18022 (b) (1), and
620	620	regardless of whether the disability insurance policy, self-insured health plan, or
621	621	pharmacy benefit manager classifies the item or service as an essential health
622	622	benefit.
623	623	(4) EXCEPTION; HIGH DEDUCTIBLE HEALTH PLANS. If applying the requirement
624	624	under sub. (2) to payments made by or on behalf of an enrollee or other individual
625	625	covered under a high deductible health plan, as defined under 26 USC 223 (c) (2),
626	626	would result in the enrollee failing to meet the definition of an eligible individual
627	627	under 26 USC 223 (c) (1), the disability insurance policy, self-insured health plan,
628	628	or pharmacy benefit manager shall begin applying the requirement under sub. (2)
629	629	to the disability insurance policy or self-insured health plan[s deductible after the
630	630	enrollee has satisfied the minimum deductible requirement under 26 USC 223 (c)
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657	657	SECTION 12
658	658	(2) (A) (i). This subsection does not apply to any amounts paid for items or services
659	659	that are preventive care, as described in 26 USC 223 (c) (2) (C).
660	660	SECTION 13. 632.865 (1) (ab) and (ac) of the statutes are created to read:
661	661	632.865 (1) (ab) X340B covered entityY has the meaning given for Xcovered
662	662	entityY under 42 USC 256b (a) (4).
663	663	(ac) X340B drugY has the meaning given for Xcovered drugY under 42 USC
664	664	256b (b) (2).
665	665	SECTION 14. 632.865 (1) (ae) of the statutes is amended to read:
666	666	632.865 (1) (ae) XHealth benefit planY has the meaning given means a health
667	667	benefit plan, as defined in s. 632.745 (11), that is not prescription drug coverage
668	668	provided under part D of medicare under Title XVIII of the federal Social Security
669	669	Act, 42 USC 1395 to 1395lll.
670	670	SECTION 15. 632.865 (1) (an), (aq) and (at) of the statutes are created to read:
671	671	632.865 (1) (an) XMaximum allowable cost listY means a list of
672	672	pharmaceutical products that sets forth the maximum amount a pharmacy benefit
673	673	manager will pay to a pharmacy or pharmacist for dispensing a pharmaceutical
674	674	product. The list may directly establish the maximum amounts or set forth a
675	675	method for how the maximum amounts are calculated.
676	676	(aq) XPharmaceutical productY means a prescription generic drug,
677	677	prescription brand-name drug, prescription biologic, or other prescription drug,
678	678	vaccine, or device.
679	679	(at) XPharmaceutical wholesalerY means a person that sells and distributes,
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704	704	JPC:cjs&skw
705	705	SECTION 15
706	706	directly or indirectly, a pharmaceutical product and that offers to deliver the
707	707	pharmaceutical product to a pharmacy or pharmacist.
708	708	SECTION 16. 632.865 (1) (bm) of the statutes is created to read:
709	709	632.865 (1) (bm) XPharmacy acquisition costY means the amount that a
710	710	pharmaceutical wholesaler charges a pharmacy or pharmacist for a
711	711	pharmaceutical product as listed on the pharmacy[s or pharmacist[s billing invoice.
712	712	SECTION 17. 632.865 (1) (cg) and (cr) of the statutes are created to read:
713	713	632.865 (1) (cg) XPharmacy benefit manager affiliateY means a pharmacy or
714	714	pharmacist that is an affiliate of a pharmacy benefit manager.
715	715	(cr) XPharmacy services administrative organizationY means an entity that
716	716	provides contracting and other administrative services to pharmacies or
717	717	pharmacists to assist them in their interactions with 3rd-party payers, pharmacy
718	718	benefit managers, pharmaceutical wholesalers, and other entities.
719	719	SECTION 18. 632.865 (2) of the statutes is repealed.
720	720	SECTION 19. 632.865 (2d) of the statutes is created to read:
721	721	632.865 (2d) PHARMACEUTICAL PRODUCT REIMBURSEMENTS . (ag) Contents of
722	722	maximum allowable cost lists. A pharmacy benefit manager that uses a maximum
723	723	allowable cost list shall include all of the following information on the maximum
724	724	allowable cost list:
725	725	1. The average acquisition cost of each pharmaceutical product and the cost of
726	726	the pharmaceutical product set forth in the national average drug acquisition cost
727	727	data published by the federal centers for medicare and medicaid services.
728	728	2. The average manufacturer price of each pharmaceutical product.
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755	755	SECTION 19
756	756	3. The average wholesale price of each pharmaceutical product.
757	757	4. The brand effective rate or generic effective rate for each pharmaceutical
758	758	product.
759	759	5. Any applicable discount indexing.
760	760	6. The federal upper limit for each pharmaceutical product published by the
761	761	federal centers for medicare and medicaid services.
762	762	7. The wholesale acquisition cost of each pharmaceutical product.
763	763	8. Any other terms that are used to establish the maximum allowable costs.
764	764	(ar) Regulation of maximum allowable cost lists. A pharmacy benefit
765	765	manager may place or continue a particular pharmaceutical product on a
766	766	maximum allowable cost list only if all of the following apply to the pharmaceutical
767	767	product:
768	768	1. The pharmaceutical product is listed as a drug product equivalent, as
769	769	defined in s. 450.13 (1e), or is rated by a nationally recognized reference, such as
770	770	Medi-Span or Gold Standard Drug Database, as Xnot ratedY or Xnot available.Y
771	771	2. The pharmaceutical product is available for purchase by all pharmacies
772	772	and pharmacists in this state from national or regional pharmaceutical wholesalers
773	773	operating in this state.
774	774	3. The pharmaceutical product has not been determined by the drug
775	775	manufacturer to be obsolete.
776	776	(b) Access and update obligations. A pharmacy benefit manager that uses a
777	777	maximum allowable cost list shall do all of the following:
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802	802	JPC:cjs&skw
803	803	SECTION 19
804	804	1. Provide access to the maximum allowable cost list to each pharmacy or
805	805	pharmacist subject to the maximum allowable cost list.
806	806	2. Update the maximum allowable cost list on a timely basis.
807	807	3. Update the maximum allowable cost list no later than 7 days after any of
808	808	the following occurs:
809	809	a. The pharmacy acquisition cost of a pharmaceutical product increases by 10
810	810	percent or more from at least 60 percent of the pharmaceutical wholesalers doing
811	811	business in this state.
812	812	b. There is a change in the methodology on which the maximum allowable
813	813	cost list is based or in the value of a variable involved in the methodology.
814	814	4. Provide a process for a pharmacy or pharmacist subject to the maximum
815	815	allowable cost list to receive prompt notification of an update to the maximum
816	816	allowable cost list.
817	817	(c) Appeal process. 1. A pharmacy benefit manager that uses a maximum
818	818	allowable cost list shall provide a process for a pharmacy or pharmacist to appeal
819	819	and resolve disputes regarding claims that the maximum payment amount for a
820	820	pharmaceutical product is below the pharmacy acquisition cost.
821	821	2. A pharmacy benefit manager required to provide an appeal process under
822	822	subd. 1. shall do all of the following:
823	823	a. Provide a dedicated telephone number and email address or website that a
824	824	pharmacy or pharmacist may use to submit an appeal.
825	825	b. Allow a pharmacy or pharmacist to submit an appeal directly on the
826	826	pharmacy[s or pharmacist[s own behalf.
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853	853	SECTION 19
854	854	c. Allow a pharmacy services administrative organization to submit an appeal
855	855	on behalf of a pharmacy or pharmacist.
856	856	d. Provide at least 7 business days after a customer transaction for a
857	857	pharmacy or pharmacist to submit an appeal under this paragraph concerning a
858	858	pharmaceutical product involved in the transaction.
859	859	3. A pharmacy benefit manager that receives an appeal from or on behalf of a
860	860	pharmacy or pharmacist under this paragraph shall resolve the appeal and notify
861	861	the pharmacy or pharmacist of the pharmacy benefit manager[s determination no
862	862	later than 7 business days after the appeal is received by doing any of the following:
863	863	a. If the pharmacy benefit manager grants the relief requested in the appeal,
864	864	the pharmacy benefit manager shall make the requested change in the maximum
865	865	allowable cost; allow the pharmacy or pharmacist to reverse and rebill the relevant
866	866	claim; provide to the pharmacy or pharmacist the national drug code number
867	867	published in a directory by the federal food and drug administration on which the
868	868	increase or change is based; and make the change effective for each similarly
869	869	situated pharmacy or pharmacist subject to the maximum allowable cost list.
870	870	b. If the pharmacy benefit manager denies the relief requested in the appeal,
871	871	the pharmacy benefit manager shall provide to the pharmacy or pharmacist a
872	872	reason for the denial, the national drug code number published in a directory by the
873	873	federal food and drug administration for the pharmaceutical product to which the
874	874	claim relates, and the name of a national or regional pharmaceutical wholesaler
875	875	operating in this state that has the pharmaceutical product currently in stock at a
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901	901	SECTION 19
902	902	price below the amount specified in the pharmacy benefit manager[s maximum
903	903	allowable cost list.
904	904	4. Notwithstanding subd. 3. b., a pharmacy benefit manager may not deny a
905	905	pharmacy[s or pharmacist[s appeal under this paragraph if the relief requested in
906	906	the appeal relates to the maximum allowable cost for a pharmaceutical product that
907	907	is not available for the pharmacy or pharmacist to purchase at a cost that is below
908	908	the pharmacy acquisition cost from the pharmaceutical wholesaler from which the
909	909	pharmacy or pharmacist purchases the majority of pharmaceutical products for
910	910	resale. If this subdivision applies, the pharmacy benefit manager shall revise the
911	911	maximum allowable cost list to increase the maximum allowable cost for the
912	912	pharmaceutical product to an amount equal to or greater than the pharmacy[s or
913	913	pharmacist[s pharmacy acquisition cost and allow the pharmacy or pharmacist to
914	914	reverse and rebill each claim affected by the pharmacy[s or pharmacist[s inability to
915	915	procure the pharmaceutical product at a cost that is equal to or less than the
916	916	maximum allowable cost that was the subject of the pharmacy[s or pharmacist[s
917	917	appeal.
918	918	(d) Affiliated reimbursements. A pharmacy benefit manager may not
919	919	reimburse a pharmacy or pharmacist in this state an amount less than the amount
920	920	that the pharmacy benefit manager reimburses a pharmacy benefit manager
921	921	affiliate for providing the same pharmaceutical product. The reimbursement
922	922	amount shall be calculated on a per unit basis based on the same generic product
923	923	identifier or generic code number, if applicable.
924	924	(e) Declining to dispense. A pharmacy or pharmacist may decline to provide a
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951	951	SECTION 19
952	952	pharmaceutical product to an individual or pharmacy benefit manager if, as a
953	953	result of the applicable maximum allowable cost list, the pharmacy or pharmacist
954	954	would be paid less than the pharmacy acquisition cost of the pharmacy or
955	955	pharmacist providing the pharmaceutical product.
956	956	SECTION 20. 632.865 (2h) of the statutes is created to read:
957	957	632.865 (2h) PROFESSIONAL DISPENSING FEES. A pharmacy benefit manager
958	958	shall pay a pharmacy or pharmacist a professional dispensing fee at a rate not less
959	959	than is paid by this state under the medical assistance program under subch. IV of
960	960	ch. 49 for each pharmaceutical product that the pharmacy or pharmacist dispenses
961	961	to an individual. The fee shall be calculated on a per unit basis based on the same
962	962	generic product identifier or generic code number, if applicable. The pharmacy
963	963	benefit manager shall pay the professional dispensing fee in addition to the amount
964	964	the pharmacy benefit manager reimburses the pharmacy or pharmacist for the cost
965	965	of the pharmaceutical product that the pharmacy or pharmacist dispenses to the
966	966	individual.
967	967	SECTION 21. 632.865 (2p) of the statutes is created to read:
968	968	632.865 (2p) PHARMACY BENEFIT MANAGER-IMPOSED FEES PROHIBITED. A
969	969	pharmacy benefit manager may not assess, charge, or collect any form of
970	970	remuneration that passes from a pharmacy or pharmacist to the pharmacy benefit
971	971	manager, including claim-processing fees, performance-based fees, network-
972	972	participation fees, or accreditation fees.
973	973	SECTION 22. 632.865 (2t) of the statutes is created to read:
974	974	632.865 (2t) FIDUCIARY DUTY AND DISCLOSURES TO HEALTH BENEFIT PLAN
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998	998	ASSEMBLY BILL 173
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1001	1001	SECTION 22
1002	1002	SPONSORS. (a) A pharmacy benefit manager owes a fiduciary duty to the health
1003	1003	benefit plan sponsor to act according to the health benefit plan sponsor[s
1004	1004	instructions and in the best interests of the health benefit plan sponsor.
1005	1005	(b) A pharmacy benefit manager shall annually provide the health benefit
1006	1006	plan sponsor with all of the following information from the previous calendar year:
1007	1007	1. The indirect profit received by the pharmacy benefit manager from owning
1008	1008	any interest in a pharmacy or health service provider.
1009	1009	2. Any payment made by the pharmacy benefit manager to a consultant or
1010	1010	broker who works on behalf of the health benefit plan sponsor.
1011	1011	3. From the amounts received from all drug manufacturers, the amounts
1012	1012	retained by the pharmacy benefit manager, and not passed through to the health
1013	1013	benefit plan sponsor, that are related to the health benefit plan sponsor[s claims or
1014	1014	bona fide service fees.
1015	1015	4. The amounts, including pharmacy access and audit recovery fees, received
1016	1016	from all pharmacies and pharmacists that are in the pharmacy benefit manager[s
1017	1017	network or have a contract to be in the network and, from these amounts, the
1018	1018	amount retained by the pharmacy benefit manager and not passed through to the
1019	1019	health benefit plan sponsor.
1020	1020	SECTION 23. 632.865 (4) of the statutes is renumbered 632.865 (4) (a).
1021	1021	SECTION 24. 632.865 (4) (b) of the statutes is created to read:
1022	1022	632.865 (4) (b) A pharmacy benefit manager may not use any certification or
1023	1023	accreditation requirement as a determinant of pharmacy network participation
1024	1024	that is inconsistent with, more stringent than, or in addition to the federal
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1048	1048	ASSEMBLY BILL 173
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1050	1050	JPC:cjs&skw
1051	1051	SECTION 24
1052	1052	requirements for licensure as a pharmacy and the requirements for licensure as a
1053	1053	pharmacy under s. 450.06 or 450.065.
1054	1054	SECTION 25. 632.865 (4m) of the statutes is created to read:
1055	1055	632.865 (4m) PROMPT PAYMENT REQUIRED. A pharmacy benefit manager
1056	1056	shall remit payment for a claim to a pharmacy or pharmacist within 30 days from
1057	1057	the day that the claim is submitted to the pharmacy benefit manager by the
1058	1058	pharmacy or pharmacist.
1059	1059	SECTION 26. 632.865 (5) (e) of the statutes is repealed.
1060	1060	SECTION 27. 632.865 (5d) of the statutes is created to read:
1061	1061	632.865 (5d) DISCRIMINATORY REIMBURSEMENT PROHIBITED. (a) In this
1062	1062	subsection, X3rd-party payerY means an entity, other than a patient or health care
1063	1063	provider, that reimburses for and manages health care expenses.
1064	1064	(b) A pharmacy benefit manager may not do any of the following:
1065	1065	1. Refuse to reimburse a 340B covered entity or a pharmacy or pharmacist
1066	1066	contracted with a 340B covered entity for dispensing 340B drugs.
1067	1067	2. Impose requirements or restrictions on 340B covered entities or
1068	1068	pharmacies or pharmacists contracted with 340B covered entities that are not
1069	1069	imposed on other entities, pharmacies, or pharmacists.
1070	1070	3. Reimburse a 340B covered entity or a pharmacy or pharmacist contracted
1071	1071	with a 340B covered entity for a 340B drug at a rate lower than the amount paid for
1072	1072	the same drug to pharmacies or pharmacists that are not 340B covered entities or
1073	1073	pharmacies or pharmacists contracted with a 340B covered entity.
1074	1074	4. Assess a fee, charge back, or other adjustment against a 340B covered
1075	1075	1
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1098	1098	ASSEMBLY BILL 173
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1101	1101	SECTION 27
1102	1102	entity or a pharmacy or pharmacist contracted with a 340B covered entity after a
1103	1103	claim has been paid or adjudicated.
1104	1104	5. Restrict the access of a 340B covered entity or a pharmacy or pharmacist
1105	1105	contracted with a 340B covered entity to a 3rd-party payer[s pharmacy network
1106	1106	solely because the 340B covered entity or the pharmacy or pharmacist contracted
1107	1107	with a 340B covered entity participates in the 340B drug pricing program under 42
1108	1108	USC 256b.
1109	1109	6. Require a 340B covered entity or a pharmacy or pharmacist contracted
1110	1110	with a 340B covered entity to contract with a specific pharmacy or pharmacist or
1111	1111	health benefit plan in order to access a 3rd-party payer[s pharmacy network.
1112	1112	7. Impose a restriction or an additional charge on a patient who obtains a
1113	1113	340B drug from a 340B covered entity or a pharmacy or pharmacist contracted with
1114	1114	a 340B covered entity.
1115	1115	8. Restrict the methods by which a 340B covered entity or a pharmacy or
1116	1116	pharmacist contracted with a 340B covered entity may dispense or deliver 340B
1117	1117	drugs.
1118	1118	9. Require a 340B covered entity or a pharmacy or pharmacist contracted
1119	1119	with a 340B covered entity to share pharmacy bills or invoices with a pharmacy
1120	1120	benefit manager, a 3rd-party payer, or a health benefit plan.
1121	1121	SECTION 28. 632.865 (5h) of the statutes is created to read:
1122	1122	632.865 (5h) REGULATION OF PHARMACY NETWORKS AND INDIVIDUAL CHOICE.
1123	1123	All of the following apply to a pharmacy benefit manager that sells access to
1124	1124	networks of pharmacies or pharmacists that operate in this state:
1125	1125	1
1126	1126	2
1127	1127	3
1128	1128	4
1129	1129	5
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1150	1150	JPC:cjs&skw
1151	1151	SECTION 28
1152	1152	(a) The pharmacy benefit manager shall allow a participant or beneficiary of
1153	1153	a pharmacy benefits plan or program that the pharmacy benefit manager serves to
1154	1154	use any pharmacy or pharmacist in this state that is licensed to dispense the
1155	1155	pharmaceutical product that the participant or beneficiary seeks to obtain,
1156	1156	provided that the pharmacy or pharmacist accepts the same terms and conditions
1157	1157	that the pharmacy benefit manager has established for at least one of the networks
1158	1158	of pharmacies or pharmacists the pharmacy benefit manager has established to
1159	1159	serve individuals in this state.
1160	1160	(b) The pharmacy benefit manager may establish a preferred network of
1161	1161	pharmacies or pharmacists and a nonpreferred network of pharmacies or
1162	1162	pharmacists, but the pharmacy benefit manager may not prohibit a pharmacy or
1163	1163	pharmacist from participating in either type of network in this state, provided that
1164	1164	the pharmacy or pharmacist is licensed by this state and the federal government
1165	1165	and accepts the same terms and conditions that the pharmacy benefit manager has
1166	1166	established for other pharmacies or pharmacists participating in the network that
1167	1167	the pharmacy or pharmacist wants to join.
1168	1168	(c) The pharmacy benefit manager may not charge a participant or
1169	1169	beneficiary of a pharmacy benefits plan or program that the pharmacy benefit
1170	1170	manager serves a different copayment obligation or additional fee, or provide any
1171	1171	inducement or financial incentive, for the participant or beneficiary to use a
1172	1172	pharmacy or pharmacist in a particular network of pharmacies or pharmacists the
1173	1173	pharmacy benefit manager has established to serve individuals in this state.
1174	1174	SECTION 29. 632.865 (5p) of the statutes is created to read:
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1201	1201	SECTION 29
1202	1202	632.865 (5p) GAG CLAUSES PROHIBITED. A pharmacy benefit manager may
1203	1203	not prohibit a pharmacy or pharmacist that dispenses a pharmaceutical product
1204	1204	from, nor may a pharmacy benefit manager penalize the pharmacy or pharmacist
1205	1205	for, informing an individual about the cost of the pharmaceutical product, the
1206	1206	amount in reimbursement that the pharmacy or pharmacist receives for dispensing
1207	1207	the pharmaceutical product, the cost and clinical efficacy of a less expensive
1208	1208	alternative to the pharmaceutical product, or any difference between the cost to the
1209	1209	individual under the individual[s pharmacy benefits plan or program and the cost
1210	1210	to the individual if the individual purchases the pharmaceutical product without
1211	1211	making a claim for benefits under the individual[s pharmacy benefits plan or
1212	1212	program.
1213	1213	SECTION 30. 632.865 (5t) of the statutes is created to read:
1214	1214	632.865 (5t) EXCLUSION OF PHARMACIES PROHIBITED. No pharmacy benefit
1215	1215	manager, 3rd-party payer, or health benefit plan may exclude a pharmacy or
1216	1216	pharmacist from its network because the pharmacy or pharmacist serves less than
1217	1217	a certain portion of the population of the state or serves a population living with
1218	1218	certain health conditions.
1219	1219	SECTION 31. 632.865 (6) (bm) of the statutes is created to read:
1220	1220	632.865 (6) (bm) Requirements of audits. An entity that conducts audits of
1221	1221	pharmacists of pharmacies shall ensure all of the following:
1222	1222	1. Each pharmacist or pharmacy audited by the entity is audited under the
1223	1223	same standards and parameters as other similarly situated pharmacists or
1224	1224	pharmacies audited by the entity.
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1251	1251	SECTION 31
1252	1252	2. The entity randomizes the prescriptions that the entity audits and the
1253	1253	entity audits the same number of prescriptions in each prescription benefit tier.
1254	1254	3. Each audit of a prescription reimbursed under Part D of Medicare under 42
1255	1255	USC 1395w-101 et seq. is conducted separately from audits of prescriptions
1256	1256	reimbursed under other policies or plans.
1257	1257	SECTION 32. 632.865 (6) (c) 3. of the statutes is amended to read:
1258	1258	632.865 (6) (c) 3. Deliver to the pharmacist or pharmacy a final audit report,
1259	1259	which may be delivered electronically, within 90 days of the date the pharmacist or
1260	1260	pharmacy receives the preliminary report or the date of the final appeal of the
1261	1261	audit, whichever is later. The final audit report under this subdivision shall
1262	1262	include specific documentation of any alleged errors and shall include any response
1263	1263	provided to the auditor by the pharmacy or pharmacist and consider and address
1264	1264	the pharmacy[s or pharmacist[s response.
1265	1265	SECTION 33. 632.865 (6) (c) 3m. of the statutes is created to read:
1266	1266	632.865 (6) (c) 3m. If the entity delivers to the pharmacist or pharmacy a
1267	1267	preliminary report of the audit or final audit report that references a billing code,
1268	1268	drug code, or other code associated with audits, provide an electronic link to a plain
1269	1269	language explanation of the code.
1270	1270	SECTION 34. 632.865 (6g) of the statutes is created to read:
1271	1271	632.865 (6g) RECOUPMENT. (a) No pharmacy benefit manager may recoup
1272	1272	any reimbursement made to a pharmacist or pharmacy for errors that have no
1273	1273	actual financial harm to an enrollee or a policy or plan sponsor unless the error is
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1296	1296	ASSEMBLY BILL 173
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1298	1298	JPC:cjs&skw
1299	1299	SECTION 34
1300	1300	the result of the pharmacist or pharmacy failing to comply with a formal corrective
1301	1301	action plan.
1302	1302	(b) No pharmacy benefit manager may use extrapolation in calculating
1303	1303	reimbursements that it may recoup. The finding of errors for which reimbursement
1304	1304	will be recouped shall be based on an actual error in reimbursement and not on a
1305	1305	projection of the number of patients served having a similar diagnosis or on a
1306	1306	projection of the number of similar orders or refills for similar prescription drugs.
1307	1307	(c) A pharmacy benefit manager that recoups any reimbursement made to a
1308	1308	pharmacist or pharmacy for an error that was the cause of financial harm shall
1309	1309	return the recouped reimbursement to the enrollee or the policy or plan sponsor
1310	1310	who was harmed by the error.
1311	1311	SECTION 35. 632.865 (6r) of the statutes is created to read:
1312	1312	632.865 (6r) QUALITY PROGRAMS. No pharmacy benefit manager may base
1313	1313	any criteria of a quality program in a contract between a pharmacy and a pharmacy
1314	1314	benefit manager on a factor for which the pharmacy does not have complete and
1315	1315	exclusive control.
1316	1316	SECTION 36. 632.865 (8) of the statutes is created to read:
1317	1317	632.865 (8) RETALIATION PROHIBITED. (a) In this subsection, XretaliateY
1318	1318	includes any of the following actions taken by a pharmacy benefit manager:
1319	1319	1. Terminating or refusing to renew a contract with a pharmacy or
1320	1320	pharmacist.
1321	1321	2. Subjecting a pharmacy or pharmacist to increased audits.
1322	1322	1
1323	1323	2
1324	1324	3
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1346	1346	JPC:cjs&skw
1347	1347	SECTION 36
1348	1348	3. Failing to promptly pay a pharmacy or pharmacist any money the
1349	1349	pharmacy benefit manager owes to the pharmacy or pharmacist.
1350	1350	(b) A pharmacy benefit manager may not retaliate against a pharmacy or
1351	1351	pharmacist for reporting an alleged violation of this section or for exercising a right
1352	1352	or remedy under this section.
1353	1353	(c) In addition to any other remedies provided by law, a pharmacy or
1354	1354	pharmacist may bring an action in court for injunctive relief based on a violation of
1355	1355	par. (b). In addition to equitable relief, the court may, notwithstanding s. 814.04 (1),
1356	1356	award a pharmacy or pharmacist that prevails in such an action reasonable
1357	1357	attorney fees and costs in prosecuting the action.
1358	1358	SECTION 37. Initial applicability.
1359	1359	(1) AFFILIATED REIMBURSEMENTS . Except as provided in sub. (4), the
1360	1360	treatment of s. 632.865 (2d) (d) first applies to a reimbursement amount paid for on
1361	1361	a claim for reimbursement submitted on the effective date of this subsection.
1362	1362	(2) PROFESSIONAL DISPENSING FEES. Except as provided in sub. (4), the
1363	1363	treatment of s. 632.865 (2h) first applies to a pharmaceutical product that is
1364	1364	dispensed on the effective date of this subsection.
1365	1365	(3) PHARMACY BENEFIT MANAGER-IMPOSED FEES. Except as provided in sub.
1366	1366	(4), the treatment of s. 632.865 (2p) first applies to remuneration collected by a
1367	1367	pharmacy benefit manager on the effective date of this subsection.
1368	1368	(4) CONTRACTS. For a pharmacy benefit manager providing pharmacy benefit
1369	1369	manager services under a contract that contains any provision inconsistent with
1370	1370	the treatment of s. 632.861 (1m), (3g), (3r), or (4) (a) or (e) or 632.865 (1) (ab), (ac),
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1397	1397	SECTION 37
1398	1398	(ae), (an), (aq), (at), (bm), (cg), or (cr), (2), (2d), (2h), (2p), (2t), (4m), (5) (e), (5d), (5h),
1399	1399	(5p), (5t), (6) (bm) or (c) 3. or 3m., (6g), (6r), or (8), the renumbering of s. 632.865 (4),
1400	1400	or the creation of s. 632.865 (4) (b), the treatment of s. 632.861 (1m), (3g), (3r), or (4)
1401	1401	(a) or (e) or 632.865 (1) (ab), (ac), (ae), (an), (aq), (at), (bm), (cg), or (cr), (2), (2d), (2h),
1402	1402	(2p), (2t), (4m), (5) (e), (5d), (5h), (5p), (5t), (6) (bm) or (c) 3. or 3m., (6g), (6r), or (8),
1403	1403	the renumbering of s. 632.865 (4), or the creation of s. 632.865 (4) (b), as applicable,
1404	1404	first applies to the pharmacy benefit manager with respect to the pharmacy benefit
1405	1405	manager services provided under the contract on the day on which the contract
1406	1406	expires or is extended, modified, or renewed, whichever occurs first.
1407	1407	(5) APPLICATION OF PRESCRIPTION DRUG PAYMENTS.
1408	1408	(a) For policies and plans containing provisions inconsistent with the
1409	1409	treatment of s. 632.862, that treatment first applies to policy or plan years
1410	1410	beginning on January 1 of the year following the year in which this paragraph takes
1411	1411	effect, except as provided in par. (b).
1412	1412	(b) For policies or plans that are affected by a collective bargaining agreement
1413	1413	containing provisions inconsistent with the treatment of s. 632.862, that treatment
1414	1414	first applies to policy or plan years beginning on the effective date of this paragraph
1415	1415	or on the day on which the collective bargaining agreement is newly established,
1416	1416	extended, modified, or renewed, whichever is later.
1417	1417	SECTION 38. Effective dates. This act takes effect on the day after
1418	1418	publication, except as follows:
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1442	1442	JPC:cjs&skw
1443	1443	SECTION 38
1444	1444	(1) APPLICATION OF PRESCRIPTION DRUG PAYMENTS. The treatment of s.
1445	1445	632.862 takes effect on the first day of the 4th month beginning after publication.
1446	1446	(END)
1447	1447	1
1448	1448	2
1449	1449	3