AB114,16,1210 (c) If the audit involves clinical or professional judgement, conduct the audit
11by or in consultation with a pharmacist licensed in this state or the pharmacy
12examining board.
AB114,16,1413 (d) Limit the audit review to claims submitted no more than 2 years before the
14date of the audit.
AB114,16,1615 (e) Audit each pharmacist or pharmacy under the same standards and
16parameters as other similarly situated pharmacists or pharmacies.
AB114,16,1817 (f) Establish a written appeals process that allows appeals of preliminary and
18final reports and allows for mediation if either party is dissatisfied with the appeal.
AB114,16,2319 (g) Allow the pharmacist or pharmacy to use records of a hospital, physician,
20or other health care provider to validate the pharmacist's or pharmacy's records and
21use any prescription that complies with requirements of the pharmacy examining
22board to validate claims in connection with a prescription, refill of a prescription, or
23change in prescription.
AB114,16,25 24(3) Results of audit. (a) An entity that has conducted an audit of a pharmacist
25or pharmacy shall do all of the following:
11. Deliver to the pharmacist or pharmacy a preliminary report of the audit
2within 60 days after date of the conclusion of the audit.
AB114,17,53 2. Allow a pharmacist or pharmacy that is the subject of an audit at least 30
4days after the date the pharmacist or pharmacy receives the preliminary report to
5provide documentation to address any discrepancy found in the audit.
AB114,17,86 3. Deliver to the pharmacist or pharmacy a final audit report within 90 days of
7the date the pharmacist or pharmacy receives the preliminary report or the date of
8the final appeal of the audit, whichever is later.
AB114,17,119 4. Refrain from assessing a recoupment or other penalty on a pharmacist or
10pharmacy until the appeal process is exhausted and the final report under subd. 3.
11is delivered to the pharmacist or pharmacy.
AB114,17,1512 5. Base a finding of overpayment or underpayment of a claim on the actual
13overpayment or underpayment and not on a projection based on the number of
14patients served having a similar diagnosis or on the number of similar orders or
15refills for similar drugs.
AB114,17,1616 6. Exclude dispensing fees from calculations of overpayments.
AB114,17,1817 7. Refrain from using extrapolation in calculating the recoupments or penalties
18for an audit.
AB114,17,2019 8. Refrain from charging interest until the final report under subd. 3. has been
AB114,18,221 (b) If an audit of a pharmacist or pharmacy identifies a clerical or
22record-keeping error in a required document or record, the pharmacy benefit
23manager or entity conducting the audit may not request recoupment of funds from
24the pharmacist or pharmacy based on such an error unless the pharmacy benefit
25manager or entity proves the pharmacist or pharmacy intended to commit fraud or

1unless the error by the pharmacist or pharmacy results in actual financial harm to
2the pharmacy benefit manager, a health benefit plan, or a consumer.
AB114,18,63 (c) Information obtained in an audit under this section is confidential and may
4not be shared unless the information is required to be shared under state or federal
5law. An entity conducting an audit may have access to the previous audit reports on
6a particular pharmacy conducted by the same entity.
AB114,18,97 (d) Any entity that conducts an audit shall provide to the health benefit plan
8a copy of the final report of the audit and a disclosure of any recoupment amount
9assessed as a result of the audit.
AB114,18,12 10(5) Payment of auditors. A pharmacy benefit manager or entity conducting an
11audit may not pay an auditor employed by or contracted with the pharmacy benefit
12manager or entity based on a percentage of the amount recovered in an audit.
AB114,18,14 13(6) Applicability. This section does not apply to an investigative audit that is
14initiated as a result of a credible allegation of fraud or willful misrepresentation.
AB114,18,19 15649.40 Transparency reports. (1) Beginning on June 1, 2020, and annually
16thereafter, every pharmacy benefit manager shall submit to the commissioner, the
17joint committee on finance, and, under s. 13.172 (3), each standing committee of the
18legislature with jurisdiction over insurance a report that contains all of the following
19information from the previous calendar year:
AB114,18,2220 (a) The aggregate amount of all rebates that the pharmacy benefit manager
21received from all pharmaceutical manufacturers by each health benefit plan sponsor
22and for all health benefit plan sponsors combined.
AB114,18,2523 (b) The aggregate administrative fee amount that the pharmacy benefit
24manager received from all pharmaceutical manufacturers by each health benefit
25plan sponsor and for all health benefit plan sponsors combined.
1(c) The aggregate rebate amount that the pharmacy benefit manager received
2from all pharmaceutical manufacturers but retained and did not pass through to
3health benefit plan sponsors and the percentage of the aggregate rebate amount that
4is retained rebates.
AB114,19,8 5(2) The commissioner shall publish, within 60 days of receiving the report
6under sub. (1), on the office's Internet site information from the transparency report
7submitted under sub. (1). The commissioner shall publish the report information in
8a manner that does not disclose any trade secrets.
AB114,19,10 9649.45 Network adequacy. A pharmacy benefit manager shall do all of the
AB114,19,15 11(1) Provide a reasonably adequate and accessible pharmacy network for
12providing prescribed drugs or devices for a health benefit plan that allows convenient
13patient access to pharmacies within a reasonable distance from a plan participant's
14residence. A pharmacy benefit manager may not include any mail-order pharmacy
15in its calculations of network adequacy under this subsection.
AB114,19,19 16(2) Submit to the commissioner, at the time and in the manner required by the
17commissioner, a pharmacy benefit manager network adequacy report describing the
18pharmacy benefit manager network and accessibility to the network for health
19benefit plan participants.
AB114,17 20Section 17. Nonstatutory provisions.
AB114,19,2521 (1) Pharmacy benefit manager; compliance date. Notwithstanding s. 649.05,
22a pharmacy benefit manager is not required to register under s. 649.05 or to comply
23with ch. 649 until the date that is 180 days after the date of the promulgation of rules
24by the commissioner of insurance under s. 649.10, unless the commissioner specifies
25a different date on which registration or compliance is required.
1(2) Rulemaking; reconciliation with step therapy bill. If 2019 Assembly Bill
224 or 2019 Senate Bill 26 is enacted and contains criteria for when a medical
3exception to a step therapy protocol must be granted, notwithstanding the
4requirement in s. 649.10 (2) to base rules on the prescription drug benefit
5management model act of the National Association of Insurance Commissioners for
6the 2nd quarter of 2018, the commissioner of insurance shall incorporate in rules
7promulgated under s. 649.10 (2) (c) criteria for granting a medical exception that are
8identical to the criteria for granting a medical exception in 2019 Assembly Bill 24 or
92019 Senate Bill 26. The commissioner of insurance may incorporate in rules
10promulgated under s. 649.10 (2) (c) requirements and procedures for a medical
11exceptions process that do not conflict with 2019 Assembly Bill 24 or 2019 Senate Bill
1226. If 2019 Assembly Bill 24 or 2019 Senate Bill 26 is not enacted in the 2019
13legislative session, this subsection is void.
AB114,18 14Section 18. Initial applicability.
AB114,20,1715 (1) For policies and plans containing provisions inconsistent with this act, this
16act first applies to policy or plan years beginning on January 1 of the year following
17the year in which this subsection takes effect.
AB114,20,1918 (2) This act first applies to contracts with a pharmacy or pharmacist that are
19entered into, modified, or renewed on the effective date of this subsection.
AB114,19 20Section 19. Effective date.
AB114,20,2221 (1) This act takes effect on the first day of the 4th month beginning after
AB114,20,2323 (End)