AB68: Bill Text

AB68,1531,2 (2) Allowing disclosures. (a) A disability insurance policy or self-insured health plan that provides a prescription drug benefit may not restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.

AB68,1531,11 (b) A disability insurance policy or self-insured health plan that provides a prescription drug benefit shall ensure that any pharmacy benefit manager that provides services under a contract with the policy or plan does not, with respect to such policy or plan, restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the policy or plan from informing, or penalize such pharmacy for informing, an enrollee of any differential between the out-of-pocket cost to the enrollee under the policy or plan with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.

AB68,1531,16 (3) Cost-sharing limitation. A disability insurance policy or self-insured health plan that provides a prescription drug benefit or a pharmacy benefit manager that provides services under a contract with a policy or plan may not require an enrollee to pay at the point of sale for a covered prescription drug an amount that is greater than the lowest of all of the following amounts:

AB68,1531,18 (a) The cost-sharing amount for the prescription drug for the enrollee under the policy or plan.

AB68,1531,21 (b) The amount a person would pay for the prescription drug if the enrollee purchased the prescription drug at the dispensing pharmacy without using any health plan or health insurance coverage.

AB68,1532,10 (4) Drug substitution. (a) Except as provided in par. (b), a disability insurance policy that offers a prescription drug benefit, a self-insured health plan that offers a prescription drug benefit, or a pharmacy benefit manager acting on behalf of a disability insurance policy or self-insured health plan shall provide to an enrollee advanced written notice of a formulary change that removes a prescription drug from the formulary of the policy or plan or that reassigns a prescription drug to a benefit tier for the policy or plan that has a higher deductible, copayment, or coinsurance. The advanced written notice of a formulary change under this paragraph shall be provided no fewer than 30 days before the expected date of the removal or reassignment and shall include information on the procedure for the enrollee to request an exception to the formulary change. The policy, plan, or pharmacy benefit manager is required to provide the advanced written notice under this paragraph only to those enrollees in the policy or plan who are using the drug at the time the notification must be sent according to available claims history.

AB68,1532,13 (b) 1. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if the prescription drug that is to be removed or reassigned is any of the following:

AB68,1532,14 a. No longer approved by the federal food and drug administration.

AB68,1532,17 b. The subject of a notice, guidance, warning, announcement, or other statement from the federal food and drug administration relating to concerns about the safety of the prescription drug.

AB68,1532,19 c. Approved by the federal food and drug administration for use without a prescription.

AB68,1533,2 2. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if, for the prescription drug that is being removed from the formulary or reassigned to a benefit tier that has a higher deductible, copayment, or coinsurance, the policy, plan, or pharmacy benefit manager adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:

AB68,1533,4 a. The same benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,6 b. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,14 (c) A pharmacist or pharmacy shall notify an enrollee in a disability insurance policy or self-insured health plan if a prescription drug for which an enrollee is filling or refilling a prescription is removed from the formulary and the policy or plan or a pharmacy benefit manager acting on behalf of a policy or plan adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:

AB68,1533,16 1. The same benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,18 2. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.

AB68,1533,25 (d) If an enrollee has had an adverse reaction to the generic prescription drug or the prescription drug in the same pharmacologic class or with the same mechanism of action that is being substituted for an originally prescribed drug, the pharmacist or pharmacy may extend the prescription order for the originally prescribed drug to fill one 30-day supply of the originally prescribed drug for the cost-sharing amount that applies to the prescription drug at the time of the substitution.

AB68,2956 Section 2956. 632.862 of the statutes is created to read:

AB68,1534,3 632.862 Application of prescription drug payments. (1) Definitions. In this section:

AB68,1534,4 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).

AB68,1534,5 (b) “Brand name drug” means any of the following:

AB68,1534,7 1. A prescription drug that contains a brand name and that has no generic equivalent.

AB68,1534,11 2. A prescription drug that contains a brand name and has a generic equivalent but for which the enrollee has received prior authorization from the insurer offering the disability insurance policy or the self-insured health plan or authorization from a physician to obtain the prescription drug under the policy or plan.

AB68,1534,12 (c) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).

AB68,1534,13 (d) “Prescription drug” has the meaning given in s. 450.01 (20)

AB68,1534,14 (e) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).

AB68,1534,20 (2) Application of discounts. A disability insurance policy that offers a prescription drug benefit or a self-insured health plan shall apply to any calculation of an out-of-pocket maximum and to any deductible of the policy or plan for an enrollee the amount that any discount provided by the manufacturer of a brand name drug reduces the cost sharing amount charged to an enrollee for that brand name drug.

AB68,2957 Section 2957. 632.863 of the statutes is created to read:

AB68,1534,22 632.863 Pharmaceutical representatives. (1) Definitions. In this section:

AB68,1534,25 (a) “Health care professional” means a physician or other health care practitioner who is licensed to provide health care services or to prescribe pharmaceutical or biologic products.

AB68,1535,2 (b) “Pharmaceutical” means a medication that may legally be dispensed only with a valid prescription from a health care professional.

AB68,1535,5 (c) “Pharmaceutical representative” means an individual who markets or promotes pharmaceuticals to health care professionals on behalf of a pharmaceutical manufacturer for compensation.

AB68,1535,9 (d) “Wholesale acquisition cost” means the most recently reported manufacturer list or catalog price for a brand-name drug or generic drug available to wholesalers or direct purchasers in the United States, before application of discounts, rebates, or reductions in price.

AB68,1535,15 (2) Licensure. (a) No individual may act as a pharmaceutical representative in this state without obtaining a pharmaceutical representative license. In order to obtain a license, an individual shall apply to the commissioner, on a form prescribed by the commissioner. A license issued under this paragraph shall be renewed on an annual basis. The application to obtain or renew a license shall include all of the following information:

AB68,1535,17 1. The applicant's full name, residence address and telephone number, and business address and telephone number.

AB68,1535,18 2. A description of the type of work in which the applicant will engage.

AB68,1535,19 3. The fee under s. 601.31 (1) (nv).

AB68,1535,21 4. An attestation that the applicant meets the professional education requirements under sub. (3).

AB68,1535,22 5. Proof that the applicant has paid any assessed penalties and fees.

AB68,1535,23 6. Any other information required by the commissioner.

AB68,1536,3 (b) The pharmaceutical representative shall report, in writing, to the commissioner any change to the information submitted on the application under par. (a) or any material change to the pharmaceutical representative's business operations or to any information provided under this section. The report shall be made no later than 4 business days after the change or material change occurs.

AB68,1536,5 (c) A pharmaceutical representative shall display his or her license during each visit with a health care professional.

AB68,1536,10 (3) Professional education requirements. (a) In order to become initially licensed under sub. (2) (a), a pharmaceutical representative shall complete a professional education course as determined by the commissioner. A pharmaceutical representative shall, upon request, provide the commissioner with proof of the coursework's completion.

AB68,1536,14 (b) In order to renew a license under sub. (2) (a), a pharmaceutical representative shall complete a minimum of 5 hours of continuing professional education courses. A pharmaceutical representative shall, upon request, provide the commissioner with proof of the coursework's completion.

AB68,1536,18 (c) The professional education coursework required under pars. (a) and (b) shall include training in ethical standards, whistleblower protections, laws and rules applicable to pharmaceutical marketing, and other areas that the commissioner may identify by rule.

AB68,1536,20 (d) The commissioner shall regularly designate courses that fulfill the requirements under this subsection and publish a list of the designated courses.

AB68,1536,25 (e) The professional education coursework required under this subsection may not be provided by the employer of a pharmaceutical representative or be funded, in any way, by the pharmaceutical industry or a 3rd party funded by the pharmaceutical industry. A provider of a course designated under par. (d) shall disclose any conflict of interest.

AB68,1537,4 (4) Disclosure to commissioner. (a) No later than June 1 of each year, a pharmaceutical representative shall provide to the commissioner, in the manner prescribed by the commissioner, all of the following information from the previous calendar year:

AB68,1537,7 1. The total number of times the pharmaceutical representative contacted health care professionals in this state and the specialties of the health care professionals contacted.

AB68,1537,11 2. For each contact with a health care professional in this state, the location and duration of the contact, the pharmaceuticals for which the pharmaceutical representative provides information, and the value of any item, including a product sample, compensation, material, or gift, provided to the health care professional.

AB68,1537,14 (b) The commissioner shall publish the information provided under par. (a) on the commissioner's Internet site in a manner in which individual health care professionals are not identifiable by name or other identifiers.

AB68,1537,20 (5) Disclosure to health care professionals. During each contact with a health care professional, a pharmaceutical representative shall disclose the wholesale acquisition cost of any pharmaceutical for which the pharmaceutical representative provides information and the names of at least 3 generic prescription drugs from the same therapeutic class, or if 3 are not available, as many as are available for prescriptive use.

AB68,1537,25 (6) Ethical standards. The commissioner shall promulgate a rule that contains ethical standards for pharmaceutical representatives and shall publish the ethical standards on the commissioner's Internet site. In addition to the ethical standards contained in the rule, a pharmaceutical representative may not do any of the following:

AB68,1538,3 (a) Engage in deceptive or misleading marketing of a pharmaceutical, including the knowing concealment, suppression, omission, misleading representation, or misstatement of a material fact.

AB68,1538,8 (b) Use a title or designation that could reasonably lead a licensed health care professional, or an employee or representative of a licensed health care professional, to believe that the pharmaceutical representative is licensed to practice medicine, nursing, dentistry, optometry, pharmacy, or other similar health occupation in this state unless the pharmaceutical representative holds a license to practice.

AB68,1538,9 (c) Attend a patient examination without the patient's consent.

AB68,1538,12 (7) Enforcement. (a) Any individual violating this section shall be fined not less than $1,000 nor more than $3,000 for each offense. Each day the violation continues shall constitute a separate offense.

AB68,1538,18 (b) The commissioner may suspend or revoke the license of a pharmaceutical representative who violates this section. A suspended or revoked license may not be reinstated until all violations related to the suspension or revocation have been remedied and all assessed penalties and fees have been paid. An individual whose pharmaceutical representative license is revoked for any cause may not be issued a license under sub. (2) (a) until at least 2 years after the date of revocation.

AB68,1538,22 (c) A health care professional who meets with a pharmaceutical representative who does not display his or her license or share the information required under sub. (5) may report the pharmaceutical representative to the commissioner for further action.

AB68,1538,23 (8) Rules. The commissioner may promulgate rules to implement this section.

AB68,2958 Section 2958. 632.864 of the statutes is created to read:

AB68,1539,2 632.864 Pharmacy services administrative organizations. (1) Definitions. In this section:

AB68,1539,3 (a) “Administrative service” means any of the following:

AB68,1539,4 1. Assisting with claims.

AB68,1539,5 2. Assisting with audits.

AB68,1539,6 3. Providing centralized payment.

AB68,1539,7 4. Performing certification in a specialized care program.

AB68,1539,8 5. Providing compliance support.

AB68,1539,9 6. Setting flat fees for generic drugs.

AB68,1539,10 7. Assisting with store layout.

AB68,1539,11 8. Managing inventory.

AB68,1539,12 9. Providing marketing support.

AB68,1539,13 10. Providing management and analysis of payment and drug dispensing data.

AB68,1539,14 11. Providing resources for retail cash cards.

AB68,1539,17 (b) “Independent pharmacy" means a pharmacy operating in this state that is licensed under s. 450.06 or 450.065 and is under common ownership with no more than 2 other pharmacies.

AB68,1539,18 (c) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).

AB68,1539,20 (d) “Pharmacy services administrative organization” means an entity operating in this state that does all of the following:

AB68,1539,22 1. Contracts with an independent pharmacy to conduct business on the pharmacy's behalf with a 3rd-party payer.

AB68,1539,25 2. Provides at least one administrative service to an independent pharmacy and negotiates and enters into a contract with a 3rd-party payer or pharmacy benefit manager on behalf of the pharmacy.

AB68,1540,3 (e) “Third-party payer” means an entity, including a plan sponsor, health maintenance organization, or insurer, operating in this state that pays or insures health, medical, or prescription drug expenses on behalf of beneficiaries.

AB68,1540,8 (2) Licensure. (a) A person may not operate as a pharmacy services administrative organization in this state without a pharmacy services administrative organization license. In order to obtain a license, a person shall apply to the commissioner in the form and manner prescribed by the commissioner. The application shall include all of the following:

AB68,1540,10 1. The name, address, telephone number, and federal employer identification number of the applicant.

AB68,1540,12 2. The name, business address, and telephone number of a contact person for the applicant.

AB68,1540,13 3. The fee under s. 601.31 (1) (nw).

AB68,1540,14 4. Evidence of financial responsibility of at least $1,000,000.

AB68,1540,15 5. Any other information required by the commissioner.

AB68,1540,17 (b) The term of a license issued under par. (a) shall be 2 years from the date of issuance.

AB68,1540,21 (3) Disclosure to the commissioner. (a) A pharmacy services administrative organization shall disclose to the commissioner the extent of any ownership or control of the pharmacy services administrative organization by an entity that does any of the following:

AB68,1540,22 1. Provides pharmacy services.