(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.
15649.40 Transparency reports. (1)
Beginning on June 1, 2020, and annually 16
thereafter, every pharmacy benefit manager shall submit to the commissioner, the 17
joint committee on finance, and, under s. 13.172 (3), each standing committee of the 18
legislature with jurisdiction over insurance a report that contains all of the following 19
information from the previous calendar year:
(a) The aggregate amount of all rebates that the pharmacy benefit manager 21
received from all pharmaceutical manufacturers by each health benefit plan sponsor 22
and for all health benefit plan sponsors combined.
(b) The aggregate administrative fee amount that the pharmacy benefit 24
manager received from all pharmaceutical manufacturers by each health benefit 25
plan sponsor and for all health benefit plan sponsors combined.
(c) The aggregate rebate amount that the pharmacy benefit manager received 2
from all pharmaceutical manufacturers but retained and did not pass through to 3
health benefit plan sponsors and the percentage of the aggregate rebate amount that 4
is retained rebates.
The commissioner shall publish, within 60 days of receiving the report 6
under sub. (1), on the office's Internet site information from the transparency report 7
submitted under sub. (1). The commissioner shall publish the report information in 8
a manner that does not disclose any trade secrets.
9649.45 Network adequacy.
A pharmacy benefit manager shall do all of the 10
Provide a reasonably adequate and accessible pharmacy network for 12
providing prescribed drugs or devices for a health benefit plan that allows convenient 13
patient access to pharmacies within a reasonable distance from a plan participant's 14
residence. A pharmacy benefit manager may not include any mail-order pharmacy 15
in its calculations of network adequacy under this subsection.
Submit to the commissioner, at the time and in the manner required by the 17
commissioner, a pharmacy benefit manager network adequacy report describing the 18
pharmacy benefit manager network and accessibility to the network for health 19
benefit plan participants.
(1) Pharmacy benefit manager; compliance date.
Notwithstanding s. 649.05, 22
a pharmacy benefit manager is not required to register under s. 649.05 or to comply 23
with ch. 649 until the date that is 180 days after the date of the promulgation of rules 24
by the commissioner of insurance under s. 649.10, unless the commissioner specifies 25
a different date on which registration or compliance is required.
(2) Rulemaking; reconciliation with step therapy bill.
If 2019 Assembly Bill 2
24 or 2019 Senate Bill 26 is enacted and contains criteria for when a medical 3
exception to a step therapy protocol must be granted, notwithstanding the 4
requirement in s. 649.10 (2) to base rules on the prescription drug benefit 5
management model act of the National Association of Insurance Commissioners for 6
the 2nd quarter of 2018, the commissioner of insurance shall incorporate in rules 7
promulgated under s. 649.10 (2) (c) criteria for granting a medical exception that are 8
identical to the criteria for granting a medical exception in 2019 Assembly Bill 24 or 9
2019 Senate Bill 26. The commissioner of insurance may incorporate in rules 10
promulgated under s. 649.10 (2) (c) requirements and procedures for a medical 11
exceptions process that do not conflict with 2019 Assembly Bill 24 or 2019 Senate Bill 12
26. If 2019 Assembly Bill 24 or 2019 Senate Bill 26 is not enacted in the 2019 13
legislative session, this subsection is void.
(1) For policies and plans containing provisions inconsistent with this act, this 16
act first applies to policy or plan years beginning on January 1 of the year following 17
the year in which this subsection takes effect.
(2) This act first applies to contracts with a pharmacy or pharmacist that are 19
entered into, modified, or renewed on the effective date of this subsection.
This act takes effect on the first day of the 4th month beginning after 22