7(3) Cost sharing limitation.
An insurer, self-insured health plan, or a 8
pharmacy benefit manager may not require a person who is covered under a 9
disability insurance policy or self-insured health plan to pay at the point of sale for 10
a covered prescription drug an amount greater than the lowest of all of the following 11
(a) The applicable copayment for the prescription drug.
(b) The allowable claim amount for the prescription drug.
(c) The amount a person who is covered under the disability insurance policy 15
or plan would pay for the prescription drug if the person purchased the prescription 16
drug without using a disability insurance policy or any other source of prescription 17
drug benefits or discounts.
(d) The amount the pharmacist or pharmacy is reimbursed for the prescription 19
drug from the pharmacy benefit manager or insurer.
20(4) Choice of provider; penalty prohibited.
An insurer, self-insured health 21
plan, or pharmacy benefit manager is prohibited from requiring or penalizing a 22
person who is covered under a disability insurance policy or self-insured health plan 23
to use or for not using a specific retail, specific mail order, or other specific pharmacy 24
provider within the network of pharmacy providers under the policy or plan. A
prohibited penalty under this subsection includes an increase in premium, 2
deductible, copayment, or coinsurance.
3(5) Drug substitution.
(a) A disability insurance policy that offers a 4
prescription drug benefit or self-insured health plan or a pharmacy benefit manager 5
acting on behalf of a disability insurance policy or self-insured health plan may not 6
require a person covered under the policy or plan to pay an increased cost-sharing 7
amount for a newly prescribed drug or device if the substitution for the originally 8
prescribed drug or device is suggested by the policy, plan, or pharmacy benefit 9
manager and if the newly prescribed drug or device is therapeutically equivalent to 10
the originally prescribed drug or device being substituted.
(b) Every disability insurance policy that offers a prescription drug benefit, 12
self-insured health plan, and pharmacy benefit manager shall develop a procedure 13
to ensure that a policy or plan does not deny coverage to an insured or plan 14
participant during a plan year or subject the insured or plan participant to new 15
exclusions, limitations, deductibles, copayments, or coinsurance under a 16
circumstance that satisfies all of the following:
1. The prescribed drug or device was covered under the policy or plan for the 18
insured or plan participant when the insured or plan participant either enrolled in 19
coverage or renewed coverage, whichever is later.
2. A health care provider who prescribed the prescribed drug or device states, 21
in writing, that the prescribed drug or device is more suitable for the insured's or plan 22
participant's condition than alternative drugs or devices that are covered under the 23
policy or plan.
632.865 (title) and (1) of the statutes are repealed.
632.865 (2) of the statutes is renumbered 649.30 (1).
Chapter 649 of the statutes is created to read:
pharmacy benefit managers
In this chapter:
“Health benefit plan” has the meaning given in s. 632.745 (11).
“Health care provider” has the meaning given in s. 146.81 (1).
“Maximum allowable cost” means the maximum amount that a pharmacy 8
benefit manager will pay a pharmacist or pharmacy toward the cost of a prescribed 9
drug or device.
“Pharmacist" has the meaning given in s. 450.01 (15).
“Pharmacy" means an entity licensed under s. 450.06 or 450.065.
“Pharmacy benefit manager" means an entity doing business in this state 13
that contracts to provide claims processing services, to otherwise administer or 14
manage prescription drug benefits, or both on behalf of any insurer or other entity 15
that provides prescription drug benefits to residents of this state. “Pharmacy benefit 16
manager” does not include a health care provider except for a health care provider 17
that is required to obtain a license under s. 450.06, 450.065, or 450.071 and does not 18
include an entity that provides claims processing services or other administration of 19
prescription drug only for the Medical Assistance program under subch. IV of ch. 49.
“Prescribed drug or device" has the meaning given in s. 450.01 (18).
“Prescription drug benefit" means coverage of or payment or assistance for 22
prescribed drugs or devices.
“Registrant" means a pharmacy benefit manager that is registered under 24
1649.05 Registration of pharmacy benefit managers. (1)
(a) Except as 2
provided in par. (b), no person may perform any activities of a pharmacy benefit 3
manager in this state without first registering with the commissioner under this 4
(b) A pharmacy benefit manager that is an insurer with a current certificate 6
of authority issued under s. 601.04 is not required to register under this section.
(c) 1. Any pharmacy benefit manager that is required to obtain a license under 8
s. 450.06, 450.065, or 450.071 shall also register under this chapter.
2. If the pharmacy examining board revokes a license that had been granted 10
under s. 450.06, 450.065, or 450.071 to a registrant, the registrant shall notify the 11
commissioner of the revocation. The commissioner shall revoke the registration 12
under this chapter.
An applicant for registration as a pharmacy benefit manager shall do all 14
of the following:
(a) File with the commissioner an application on a form that the commissioner 16
(b) Pay any registration fee set by the commissioner.
The commissioner shall register any pharmacy benefit manager that meets 19
the requirements of this chapter and any requirements the commissioner requires 20
of applicants. Registration under this section is valid for one year unless registration 21
is suspended or revoked. The commissioner may refuse to register any pharmacy 22
benefit manager for which a previous registration was suspended or revoked.
23649.10 Powers and duties of the commissioner. (1)
The commissioner 24
may do any of the following:
(a) Promulgate rules necessary to carry out the intent of this chapter.
(b) Use authority granted under ss. 601.41, 601.42, 601.43, 601.44, 601.61, 2
601.62, 601.63, and 601.64 to enforce this chapter, s. 628.36, and ch. 632 as it relates 3
to pharmacy benefit managers.
The commissioner shall promulgate rules regarding all of the following 5
using as a model the prescription drug benefit management model act of the National 6
Association of Insurance Commissioners for the 2nd quarter of 2018 to the extent the 7
model act does not conflict with this chapter or ch. 632:
(a) Requirements for the development and maintenance of prescription drug 9
formularies and other pharmacy benefit manager procedures, except that the 10
commissioner may not allow a health benefit plan, self-insured health plan, or 11
pharmacy benefit manager to require a consumer to obtain a prescription drug at a 12
mail order pharmacy because the prescription drug requires special handling, 13
provider coordination, or patient education.
(b) Information that the pharmacy benefit manager is required to provide to 15
a person who is covered or who seeks to be covered under a health benefit plan or 16
self-insured health plan, a prescriber of prescription drugs, or a pharmacist or 17
(c) Requirements and procedures for a medical exceptions approval process 19
that is standardized among pharmacy benefit managers.
(d) Requirements for nondiscrimination in prescription drug benefit design.
(e) Requirements for record keeping and reporting by a pharmacy benefit 22
(f) Responsibilities for the pharmacy benefit manager in oversight and 24
(g) Required disclosures by a health benefit plan or self-insured health plan 2
or a pharmacy benefit manager.
3649.20 Suspension or revocation of registration; penalty. (1)
commissioner, after a hearing, may suspend or revoke the registration of a 5
registrant, if the registrant or an officer, director, or employee of the registrant does 6
any of the following:
(a) Knowingly makes or causes to be made a false statement or 8
misrepresentation of a material fact in an application for registration under s. 9
(b) Obtains or attempts to obtain a registration under s. 649.05 through 11
misrepresentation or fraud.
(c) Misappropriates or converts for the registrant's own use or improperly 13
withholds insurance premiums or contributions held in a fiduciary capacity, except 14
for any interest earnings received by the pharmacy benefit manager and disclosed 15
to the pharmacist, pharmacy, or health benefit plan sponsor with which the 16
pharmacy benefit manager has a contract to provide services.
(d) Commits fraudulent, coercive, or dishonest practices in the transaction of 18
business as a pharmacy benefit manager.
(e) Uses, or knowingly permits the use of, any advertisement, promotion, 20
solicitation, representation, proposal, or offer that is untrue, deceptive, or 21
(f) Has a license or registration suspended, revoked, or not renewed in any 23
other state, district, territory, or province that impacts business conducted in this 24
(g) Knowingly violates a requirement of this chapter or ch. 632 or a rule 2
promulgated under this chapter or ch. 632.
Any person who performs the activities of a pharmacy benefit manager in 4
this state without a valid registration under s. 649.05 is subject to a forfeiture of $500 5
for each day of violation.
6649.30 Pricing transparency; prohibitions; contracts.
A pharmacy benefit manager or a representative of a 8
pharmacy benefit manager may not do any of the following:
(a) Unless approved by the commissioner, charge a pharmacist or pharmacy a 10
fee related to the adjudication of a claim, including a fee for receiving and processing 11
a pharmacy claim, developing or managing claims processing services in a pharmacy 12
benefit manager network, or participating in a pharmacy benefit manager network.
(b) Unless approved by the commissioner after consulting with the pharmacy 14
examining board, require pharmacist or pharmacy accreditation standards or 15
certification requirements in addition to, more stringent than, or inconsistent with 16
any requirements of the pharmacy examining board.
(c) Reimburse a pharmacy or pharmacist in this state an amount less than the 18
amount that the pharmacy benefit manager reimburses an affiliate of the pharmacy 19
benefit manager for providing the same services. To comply with this paragraph, the 20
pharmacy benefit manager shall compare the amounts calculated on a per-unit 21
basis using the same generic product identifier or generic code number.
(d) After termination of a pharmacy or pharmacist from a pharmacy benefit 23
network, fail to make payments to a pharmacist or pharmacy for services that were 24
properly rendered and provided before termination.
(e) Prohibit, restrict, or limit a pharmacy or pharmacist from disclosing 2
information to the commissioner, law enforcement, or a state or federal 3
governmental official that is investigating or examining a complaint or conducting 4
a review of a pharmacy benefit manager's compliance with the requirements under 5
6(3) Conflict of interest; business practices.
(a) If a pharmacy benefit 7
manager makes a formulary substitution in which the substitute drug costs more 8
than the originally prescribed drug, the pharmacy benefit manager shall disclose to 9
the health benefit plan sponsor the cost of the drugs and any benefit that accrues, 10
directly or indirectly, to the pharmacy benefit manager related to the substitution.
(b) A pharmacy benefit manager may not require that a pharmacy or 12
pharmacist enter into one contract in order to enter into another contract.
(c) A pharmacy benefit manager shall notify a health benefit plan sponsor in 14
writing of any activity, policy, or practice of the pharmacy benefit manager that 15
presents a conflict of interest, directly or indirectly, with any requirement of this 16
17(4) Retroactive claim reduction.
A pharmacy benefit manager may not 18
retroactively deny or reduce a pharmacist's or pharmacy's claim after adjudication 19
of the claim unless any of the following is true:
(a) The original claim was submitted fraudulently.
(b) The payment for the original claim was incorrect because the pharmacy or 22
pharmacist had already been paid for the pharmacy services.
(c) The pharmacy services were not rendered by the pharmacist or pharmacy.
24649.35 Audits of pharmacies or pharmacists. (1) Definition.
In this 25
section, “entity” means a defined network plan, as defined in s. 609.01 (1b), insurer,
3rd-party payer, or pharmacy benefit manager or a person acting on behalf of a 2
defined network plan, insurer, 3rd-party payer, or pharmacy benefit manager.
3(2) Audit procedure requirements.
An entity conducting an audit of 4
pharmacist or pharmacy records shall do all of the following:
(a) If the audit is an audit on the premises of the pharmacist or pharmacy, notify 6
the pharmacist or pharmacy in writing of the audit at least 2 weeks before conducting 7
(b) Refrain from auditing a pharmacist or pharmacy within the first 7 days of 9
a month unless the pharmacist or pharmacy consents to an audit during that time.
(c) If the audit involves clinical or professional judgement, conduct the audit 11
by or in consultation with a pharmacist licensed in this state or the pharmacy 12
(d) Limit the audit review to claims submitted no more than 2 years before the 14
date of the audit.
(e) Audit each pharmacist or pharmacy under the same standards and 16
parameters as other similarly situated pharmacists or pharmacies.
(f) Establish a written appeals process that allows appeals of preliminary and 18
final reports and allows for mediation if either party is dissatisfied with the appeal.
(g) Allow the pharmacist or pharmacy to use records of a hospital, physician, 20
or other health care provider to validate the pharmacist's or pharmacy's records and 21
use any prescription that complies with requirements of the pharmacy examining 22
board to validate claims in connection with a prescription, refill of a prescription, or 23
change in prescription.
24(3) Results of audit.
(a) An entity that has conducted an audit of a pharmacist 25
or pharmacy shall do all of the following:
1. Deliver to the pharmacist or pharmacy a preliminary report of the audit 2
within 60 days after date of the conclusion of the audit.
2. Allow a pharmacist or pharmacy that is the subject of an audit at least 30 4
days after the date the pharmacist or pharmacy receives the preliminary report to 5
provide documentation to address any discrepancy found in the audit.
3. Deliver to the pharmacist or pharmacy a final audit report within 90 days of 7
the date the pharmacist or pharmacy receives the preliminary report or the date of 8
the final appeal of the audit, whichever is later.
4. Refrain from assessing a recoupment or other penalty on a pharmacist or 10
pharmacy until the appeal process is exhausted and the final report under subd. 3. 11
is delivered to the pharmacist or pharmacy.
5. Base a finding of overpayment or underpayment of a claim on the actual 13
overpayment or underpayment and not on a projection based on the number of 14
patients served having a similar diagnosis or on the number of similar orders or 15
refills for similar drugs.
6. Exclude dispensing fees from calculations of overpayments.
7. Refrain from using extrapolation in calculating the recoupments or penalties 18
for an audit.
8. Refrain from charging interest until the final report under subd. 3. has been 20
(b) If an audit of a pharmacist or pharmacy identifies a clerical or 22
record-keeping error in a required document or record, the pharmacy benefit 23
manager or entity conducting the audit may not request recoupment of funds from 24
the pharmacist or pharmacy based on such an error unless the pharmacy benefit 25
manager or entity proves the pharmacist or pharmacy intended to commit fraud or
unless the error by the pharmacist or pharmacy results in actual financial harm to 2
the pharmacy benefit manager, a health benefit plan, or a consumer.
(c) Information obtained in an audit under this section is confidential and may 4
not be shared unless the information is required to be shared under state or federal 5
law. An entity conducting an audit may have access to the previous audit reports on 6
a particular pharmacy conducted by the same entity.
(d) Any entity that conducts an audit shall provide to the health benefit plan 8
a copy of the final report of the audit and a disclosure of any recoupment amount 9
assessed as a result of the audit.
10(5) Payment of auditors.
A pharmacy benefit manager or entity conducting an 11
audit may not pay an auditor employed by or contracted with the pharmacy benefit 12
manager or entity based on a percentage of the amount recovered in an audit.
This section does not apply to an investigative audit that is 14
initiated as a result of a credible allegation of fraud or willful misrepresentation.