Wisconsin Legislature: AB43: Bill Text

3. The total amount of price concessions, discounts, and rebates the
manufacturer provides to each pharmacy benefit manager for the drug.

4. The price at which therapeutic alternatives have been sold and the average
monetary concession, discount, or rebate the manufacturer provides, or is expected
to provide, to health plan payors and pharmacy benefit managers for therapeutic
alternatives.

5. The costs to health plans based on patient access consistent with federal
labeled indications and recognized standard medical practice.

6. The impact on patient access resulting from the drug's cost relative to
insurance benefit design.

7. The current or expected dollar value of drug-specific patient access
programs that are supported by the manufacturer.

8. The relative financial impacts to health, medical, or social services costs that
can be quantified and compared to baseline effects of existing therapeutic
alternatives.

9. The average patient copay or other cost sharing for the drug.

If the board determines that a prescription drug will lead to an affordability
challenge, the bill directs the board to establish an upper payment limit for that drug
that applies to all purchases and payor reimbursements of the drug dispensed or
administered to individuals in this state. In establishing the upper payment limit,
the board must consider the cost of administering the drug, the cost of delivering it
to consumers, and other relevant administrative costs. For certain drugs, the board
must solicit information from the manufacturer regarding the price increase and, if
the board determines that the price increase is not a result of the need for increased
manufacturing capacity or other effort to improve patient access during a public
health emergency, the board must establish an upper payment limit equal to the
drug's cost prior to the price increase.

Cost-sharing cap on insulin

The bill prohibits each health insurance policy and governmental self-insured
health plan that covers insulin and imposes cost sharing on prescription drugs from
imposing cost sharing on insulin in an amount that exceeds $35 for a one-month
supply. Current law requires each health insurance policy that provides coverage of
expenses incurred for treatment of diabetes to provide coverage for specified
expenses and items, including insulin. The required coverage under current law for
certain diabetes treatments other than insulin infusion pumps is subject to the same
exclusions, limitations, deductibles, and coinsurance provisions of the policy as other
covered expenses. The bill's cost-sharing limitation on insulin supersedes the
specification that the exclusions, limitations, deductibles, and coinsurance are the
same as for other coverage.

Insulin safety net programs

The bill requires insulin manufacturers to establish a program under which
qualifying residents of this state who are in urgent need of insulin and are uninsured
or have limited insurance coverage can be dispensed insulin at a pharmacy. Under
the program, if a qualifying individual in urgent need of insulin provides a pharmacy
with a form attesting that the individual meets the program's eligibility
requirements, specified proof of residency, and a valid insulin prescription, the
pharmacy must dispense a 30-day supply of insulin to the individual and may charge
the individual a copayment of no more than $35. The pharmacy may submit an
electronic payment claim for the insulin's acquisition cost to the manufacturer or
agree to receive a replacement of the same insulin in the amount dispensed.

The bill also requires that each insulin manufacturer establish a patient
assistance program to make insulin available to any qualifying resident of this state
who, among other requirements, is uninsured or has limited insurance coverage and
whose family income does not exceed 400 percent of the federal poverty line. Under
the bill, an individual must apply to participate in a manufacturer's program. If the
manufacturer determines that the individual meets the program's eligibility
requirements, the manufacturer must issue the individual a statement of eligibility,
which is valid for 12 months and may be renewed. Under the bill, if an individual
with a statement of eligibility and valid insulin prescription requests insulin from
a pharmacy, the pharmacy must submit an order to the manufacturer, who must then
provide a 90-day supply of insulin at no charge to the individual or pharmacy. The
pharmacy may charge the individual a copayment of no more than $50. Under the
bill, a manufacturer is not required to issue a statement of eligibility if the individual
has prescription drug coverage through an individual or group health plan and the
manufacturer determines that the individual's insulin needs are better addressed
through the manufacturer's copayment assistance program. In such case, the
manufacturer must provide the individual with the necessary drug coupons, and the
individual may not be required to pay more than a $50 copayment for a 90-day
supply of insulin.

Under the bill, if the manufacturer determines that an individual is not eligible
for the patient assistance program, the individual may file an appeal with OCI. The
bill directs OCI to establish procedures for deciding appeals. Under the bill, OCI
must issue a decision within 10 days, and that decision is final.

The bill requires that insulin manufacturers annually report to OCI certain
information, including the number of individuals served and the cost of insulin
dispensed under the programs, and that OCI annually report to the governor and the
legislature on the programs. The bill also directs OCI to conduct public outreach and
develop an information sheet about the programs, conduct satisfaction surveys of
individuals and pharmacies that participate in the programs, and report to the
governor and the legislature on the surveys by July 1, 2026. Additionally, the bill
requires that OCI develop a training program for health care navigators to assist
individuals in accessing appropriate long-term insulin options and maintain a list
of trained navigators.

The bill provides that a manufacturer that violates the bill's provisions may be
required to forfeit not more than $200,000 per month of violation, which increases
to $400,000 per month if the manufacturer continues to be in violation after six
months and to $600,000 per month if the manufacturer continues to be in violation
after one year. The bill's requirements do not apply to manufacturers with annual
insulin sales revenue in this state of no more than $2,000,000 or to insulin that costs
less than a specified dollar amount.

Application of manufacturer discounts

Health insurance policies and plans often apply deductibles and out-of-pocket
maximum amounts to the benefits covered by the policy or plan. A deductible is an
amount that an enrollee in a policy or plan must pay out of pocket before attaining
the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit
specified by a policy or plan on the amount that an enrollee pays, and once that limit
is reached, the policy or plan covers the benefit entirely. The bill requires health
insurance policies that offer prescription drug benefits and self-insured health plans
to apply the amount of any discounts that a manufacturer of a brand name drug
provides to reduce the amount of cost sharing that is charged to an enrollee for those
brand name drugs to the enrollee's deductible and out-of-pocket maximum amount.
That requirement applies for brand name drugs that have no generic equivalent and
for brand name drugs that have a generic equivalent but that the enrollee has prior
authorization or physician approval to obtain.

Reimbursement to federal drug pricing program participants

The bill prohibits any person from reimbursing certain entities that participate
in the federal drug pricing program, known as the 340B program, for a drug subject
to an agreement under the program at a rate lower than that paid for the same drug
to pharmacies that have a similar prescription volume. The bill also prohibits a
person from imposing any fee, charge back, or other adjustment on the basis of the
entity's participation in the 340B program. The entities covered by the prohibitions
under the bill are federally qualified health centers, critical access hospitals, and
grantees under the federal Ryan White HIV/AIDS program, as well as these entities'
pharmacies and any pharmacy with which any of the entities have contracted to
dispense drugs through the 340B program. The bill allows the commissioner to
promulgate administrative rules to establish a minimum reimbursement rate for
entities that participate in the 340B program.

Value-based diabetes medication pilot project

The bill directs OCI to develop a pilot project under which a pharmacy benefit
manager and a pharmaceutical manufacturer are directed to create a value-based,
sole-source arrangement to reduce the costs of prescription diabetes medication.
The bill allows OCI to promulgate administrative rules to implement the pilot
project.

Pharmacy services administrative organizations

The bill requires that a pharmacy services administrative organization (PSAO)
be licensed by OCI. Under the bill, a PSAO is an entity operating in Wisconsin that
does all of the following:

1. Contracts with an independent pharmacy to conduct business on the
pharmacy's behalf with a third-party payer.

2. Provides at least one administrative service to an independent pharmacy
and negotiates and enters into a contract with a third-party payer or pharmacy
benefit manager on the pharmacy's behalf.

The bill defines “independent pharmacy" to mean a licensed pharmacy
operating in this state that is under common ownership with no more than two other
pharmacies. “Administrative service” is defined to mean assisting with claims or
audits, providing centralized payment, performing certification in a specialized care
program, providing compliance support, setting flat fees for generic drugs, assisting
with store layout, managing inventory, providing marketing support, providing
management and analysis of payment and drug dispensing data, or providing
resources for retail cash cards. The bill defines “third-party payer” to mean an entity
operating in this state that pays or insures health, medical, or prescription drug
expenses on behalf of beneficiaries. The bill uses the current law definition of
“pharmacy benefit manager," which is an entity doing business in this state that
contracts to administer or manage prescription drug benefits on behalf of an insurer
or other entity that provides prescription drug benefits to Wisconsin residents.

To obtain the license required by the bill, a person must apply to OCI and
provide the contact information for the applicant and a contact person, evidence of
financial responsibility of at least $1,000,000, and any other information required by
the commissioner. Under the bill, the license fee is set by the commissioner, and the
term of a license is two years.

The bill also requires that a PSAO disclose to OCI the extent of any ownership
or control by an entity that provides pharmacy services; provides prescription drug
or device services; or manufactures, sells, or distributes prescription drugs,
biologicals, or medical devices. The PSAO must notify OCI within five days of any
material change in its ownership or control related to such an entity.

Licensure of pharmaceutical representatives

The bill requires a pharmaceutical representative to be licensed by OCI and to
display the pharmaceutical representative's license during each visit with a health
care professional. The bill defines “pharmaceutical representative” to mean an
individual who markets or promotes pharmaceuticals to health care professionals on
behalf of a pharmaceutical manufacturer for compensation. The term of a license
issued under the bill is one year, and the license is renewable. Under the bill, the
license fee is set by the commissioner of insurance. The bill directs the commissioner
to promulgate administrative rules to implement the bill's requirements, including
rules that require pharmaceutical representatives to complete continuing
educational coursework as a condition of licensure. An individual who violates any
of the requirements under the bill is subject to a fine, and the individual's license may
be suspended or revoked.

Moneys from professional regulation used for general program operations

The bill credits to the appropriation account for OCI's general program
operations all moneys received from the regulation of pharmacy benefit managers,

pharmacy benefit management brokers, pharmacy benefit management
consultants, PSAOs, and pharmaceutical representatives.

Coverage of infertility services

The bill requires health insurance policies and self-insured governmental
health plans that cover medical or hospital expenses to cover diagnosis of and
treatment for infertility and standard fertility preservation services. Coverage
required under the bill must include at least four completed egg retrievals with
unlimited embryo transfers, in accordance with certain guidelines, and single
embryo transfer is allowed when recommended and medically appropriate. Policies
and plans are prohibited from imposing an exclusion, limitation, or other restriction
on coverage of medications of which the bill requires coverage that is not imposed on
any other prescription medications covered under the policy or plan. Similarly,
policies and plans may not impose any exclusion, limitation, cost-sharing
requirement, benefit maximum, waiting period, or other restriction on diagnosis,
treatment, or services for which coverage is required under the bill that is different
from any exclusion, limitation, cost-sharing requirement, benefit maximum,
waiting period, or other restriction imposed on benefits for other services. Also,
policies and plans may not impose an exclusion, limitation, or other restriction on
diagnosis, treatment, or services for which coverage is required under the bill on the
basis that an insured person participates in fertility services provided by or to a third
party.

Coverage of treatment or services provided by qualified treatment trainees

The bill prohibits any health insurance plan from excluding coverage for
mental health or behavioral health treatment or services provided by a qualified
treatment trainee within the scope of the qualified treatment trainee's education and
training if the health insurance plan covers the mental health or behavioral health
treatment or services when provided by another health care provider. “Qualified
treatment trainee” is defined under current law to mean either a graduate student
who is enrolled in an accredited institution in psychology, counseling, marriage and
family therapy, social work, nursing, or a closely related field, or a person with a
graduate degree from an accredited institution and course work in psychology,
counseling, marriage and family therapy, social work, nursing, or a closely related
field who has not yet completed the applicable supervised practice requirements
described under the administrative code.

Coverage of treatment or services provided by substance abuse counselors

The bill prohibits any health insurance plan from excluding coverage for
alcoholism or other drug abuse treatment or services provided by a certified
substance abuse counselor within the scope of the substance abuse counselor's
education and training if the health insurance plan covers the alcoholism or other
drug abuse treatment or services when provided by another health care provider.
“Substance abuse counselor” is defined under current law to mean a substance abuse
counselor-in-training, a substance abuse counselor, or a clinical substance abuse
counselor.

Telehealth parity

The bill requires health insurance policies and self-insured governmental
health plans to cover a treatment or service that is provided through telehealth if the
treatment or service is covered by the policy or plan when provided in person. A
policy or plan may limit its coverage to those treatments or services that are
medically necessary. “Telehealth” is defined in the bill as a practice of health care
delivery, diagnosis, consultation, treatment, or transfer of medically relevant data
by means of audio, video, or data communications that are used either during a
patient visit or consultation or are used to transfer medically relevant data about a
patient. A self-insured governmental health plan is a self-funded health plan of the
state or a county, city, village, town, or school district.

The bill also sets parameters on the coverage of telehealth treatments and
services that is required in the bill. A policy or plan may not subject a telehealth
treatment or service to a greater deductible, copayment, or coinsurance than if
provided in person. Similarly, a policy or plan may not impose a policy or calendar
year or lifetime benefit limit or other maximum limitation or a prior authorization
requirement on a telehealth treatment or service that is not imposed on treatments
or services provided through manners other than telehealth. A policy or plan also
may not place unique location requirements on a telehealth treatment or service. If
a policy or plan covers a telehealth treatment or service that has no in-person
equivalent, the policy or plan must disclose this in the policy or plan materials.

State-based exchange

The bill directs OCI to establish and operate a state-based health insurance
exchange. Under current law, the federal Patient Protection and Affordable Care Act
(ACA) requires that an exchange be established in each state to facilitate the
purchase of qualified health insurance coverage by individuals and small employers.
Under the ACA, a state must operate its own state-based exchange, use the federally
facilitated exchange operated by the federal Department of Health and Human
Services, or adopt a hybrid approach under which the state operates a state-based
exchange but uses the federal platform, known as HealthCare.gov, to handle
eligibility and enrollment functions. Wisconsin currently uses the federally
facilitated exchange. The bill directs OCI to establish and operate a state-based
exchange, first by using the federal platform and then transitioning to a fully
state-run exchange. The bill authorizes OCI to enter into any agreement with the
federal government necessary to implement those provisions. The bill also requires
that OCI impose a user fee on insurers offering plans through the state-based
exchange. Under current law, the ACA imposes user fees on insurers offering plans
through federally facilitated exchanges and state-based exchanges using the federal
platform, which are currently 2.75 percent and 2.25 percent of total monthly
premiums, respectively. The bill authorizes OCI to impose a user fee at the following
rates:

1. For any plan year that OCI operates the state-based exchange using the
federal platform, the rate is 0.5 percent.

2. For the first two plan years that OCI operates the fully state-run exchange,
the rate is equal to the user fee for the federally facilitated exchanges. For later plan
years, the rate is set by OCI by rule.

The bill also creates an annual GPR appropriation for OCI's general program
operations and allows OCI to spend up to $1,000,000 from that appropriation in fiscal
year 2023-24 for the development of a public option health insurance plan.

Insurer network adequacy standards

The bill allows OCI to promulgate administrative rules to establish minimum
network time and distance standards and minimum network wait-time standards
for defined network plans and preferred provider plans. The bill specifies that OCI,
in promulgating rules under the bill, must consider standards adopted by the federal
Centers for Medicare and Medicaid Services for qualified health plans offered on the
federally-facilitated health insurance marketplace established pursuant to the
ACA.

Wisconsin Healthcare Stability Plan spending limit

The bill directs the commissioner of insurance to index for inflation the annual
maximum expenditure amount under the Wisconsin Healthcare Stability Plan
(WIHSP). Under current law, WIHSP makes a reinsurance payment to a health
insurance carrier if the claims for an individual who is enrolled in a health benefit
plan with that carrier exceed a threshold amount, known as the attachment point,
in a benefit year. WIHSP is administered by OCI and operates under specific terms
and conditions of a waiver agreement between OCI and the federal Department of
Health and Human Services, which was dated July 29, 2018. Currently, the
commissioner is limited to spending $230,000,000 for WIHSP from all revenue
sources in a year, unless JCF increases the amount.

Beginning in 2025, the bill directs the commissioner to annually adjust the
annual expenditure limit based on the increase, if any, in the medical care index of
the consumer price index. The bill also specifies that OCI's authority includes the
authority to operate WIHSP under any waiver extension approvals.

Prescription drug importation program

The bill requires the commissioner of insurance, in consultation with persons
interested in the sale and pricing of prescription drugs and federal officials and
agencies, to design and implement a prescription drug importation program for the
benefit of and that generates savings for residents of this state. The bill establishes
requirements for the program, including all of the following: 1) the commissioner
must designate a state agency to become a licensed wholesale distributor or contract
with a licensed wholesale distributor and to seek federal certification and approval
to import prescription drugs; 2) the program must comply with certain federal
regulations and import from Canadian suppliers only prescription drugs that are not
brand-name drugs, have fewer than four competitor drugs in this country, and for
which importation creates substantial savings; 3) the commissioner must ensure
that prescription drugs imported under the program are not distributed, dispensed,
or sold outside of Wisconsin; and 4) the program must have an audit procedure to
ensure the program complies with certain requirements specified in the bill. Before

submitting the proposed program to the federal government for certification, the
commissioner must submit the proposed program to JCF for its approval.

State prescription drug purchasing entity

The bill requires OCI to conduct a study on the viability of creating or
implementing a state prescription drug purchasing entity.

Short-term, limited duration plan coverage requirements

The bill sets certain coverage requirements on individual health plans that are
short-term, limited duration plans. Under current law, a short-term, limited
duration plan is individual health benefit plan coverage that is marketed and
designed to provide short-term coverage as a bridge between other coverages and
that has a term of not more than 12 months and an aggregate term of all consecutive
periods of coverage that does not exceed 18 months. Under current law, an insurer
generally must renew individual health coverage at the option of the insured, but an
insurer is not required to renew a short-term, limited duration plan.

The bill requires an insurer that offers a short-term, limited duration plan to
accept each individual who applies for coverage, regardless of whether the individual
has a preexisting condition. The bill also prohibits a short-term, limited duration
plan from imposing a preexisting condition exclusion. Under current law, a
short-term, limited duration plan may impose a preexisting condition exclusion, but
the plan must reduce the length of time of the exclusion by the aggregate duration
of the insured's consecutive periods of coverage. Under current law, a preexisting
condition exclusion is a period of time during which a plan will not cover a medical
condition for which the insured received some medical attention before the effective
date of coverage.

Under the bill, an insurer that offers a short-term, limited duration plan may
not vary premium rates for a specific plan except on the basis of 1) whether the plan
covers an individual or a family; 2) area in this state; 3) age; and 4) tobacco use, as
specified in the bill. An insurer that offers a short-term, limited duration plan is
prohibited under the bill from establishing rules for the eligibility of any individual
to enroll based on certain health status-related factors, which are specified in the
bill, and from requiring an enrollee to pay a greater premium, contribution,
deductible, copayment, or coinsurance amount than is required of a similarly
situated enrollee based on a health status-related factor. Under the bill, a
short-term, limited duration plan may not establish lifetime limits or limits for the
duration of the coverage on the dollar value of benefits for an enrollee or a dependent
of an enrollee under the plan.

Finally, the bill reduces the maximum allowable term of a short-term, limited
duration plan from 12 months to three months and reduces the maximum aggregate
duration from 18 months to six months.

Eliminate obsolete OCI appropriation

The bill eliminates an obsolete appropriation. The 2021-23 biennial budget act
required the transfer of $1,520,300 in each fiscal year of that biennium from the
unencumbered balance of the program-revenue-funded general program
operations appropriation of OCI to an interagency and intraagency operations

appropriation created in the act for the purpose of general program operations. The
bill eliminates that appropriation.

justice

Grant programs

Treatment alternatives and diversion grants

Under current law, DOJ, in collaboration with DOC and DHS, awards grants
to counties and tribes that have established qualifying treatment alternatives and
diversion (TAD) programs that offer substance abuse or mental health treatment
services as alternatives to prosecution or incarceration in order to reduce recidivism,
promote public safety, and reduce prison and jail populations.

Under current law, in order to qualify for a TAD grant, a county's or tribe's
program is required to match 25 percent of the grant and to charge participants a fee
to participate. A county or tribe that receives a TAD grant must create an oversight
committee to administer and evaluate its program. DOJ is required to make grants
available to any county or tribe on a competitive basis every five years. At the end
of the five-year grant cycle, DOJ is required to prepare a comprehensive report on
the grant program based on annual reports and other data it collects from the
counties and tribes.

Under current law, one of the appropriations used to fund the TAD grant
program provides that DOJ may use that appropriation to provide a TAD grant to
counties that were not a recipient of a TAD grant as of September 23, 2017.

The bill makes several changes to the TAD grant program. Under the bill, a
program funded by a TAD grant need not focus solely on alcohol and other drug
treatment, but must employ evidence-based practices targeted to the population
served by the program. The bill changes the match requirement from 25 percent to
10 percent and changes the competitive grant process to a four-year cycle. The bill
allows, but does not require, an eligible program to charge participants a fee for their
treatment. The bill also eliminates certain requirements pertaining to exposure of
genitals during drug testing. The bill also provides that the appropriation that was
formerly limited to providing a TAD grant to a county that had not received one as
of September 23, 2017, may be used to provide a TAD grant to a county that is not
a recipient of a TAD grant on the effective date of the bill.

Under current law, when a person pleads or is found guilty of certain drug
offenses, the court is required to order a substance use assessment. Under current
law, the court does not have to order an assessment if the person is already covered
by such an order, has recently completed an assessment under such an order, or is
participating in a TAD program. The bill specifies that if a person is participating
in any evidence-based substance use disorder treatment program as determined by
DOJ, regardless of its status relating to the TAD program, the court does not need
to order an assessment.

Community policing and community prosecution program grants

Under current law, DOJ awards grants to local governments for many
purposes, including for community-oriented policing-house programs and to
increase beat patrol officers. The bill adds that DOJ must award grants to cities,

villages, towns, counties, and tribes to fund community policing and community
prosecution programs.

Sexual assault victim services grants for the Wisconsin Coalition Against
Sexual Assault

Under current law, DOJ administers a grant program to provide grants to
organizations that provide services to victims of sexual assault. The bill requires
that, in addition to the other grants under the program, DOJ must provide an annual
grant of $343,000 to the Wisconsin Coalition Against Sexual Assault. Under the bill,
the Wisconsin Coalition Against Sexual Assault may also apply for additional grants
under the program.

Law enforcement recruitment, retention, and wellness grants

Under current law, DOJ awards grants for many purposes, including for
community-oriented policing-house programs and to increase beat patrol officers.
The bill adds that DOJ must award grants to law enforcement agencies and tribal
law enforcement agencies in this state to fund programs that recruit and retain law
enforcement officers and that promote officer wellness.

Crime victims services grants

Under current law, DOJ awards grants for many purposes, including grants to
organizations to provide services for sexual assault victims. The bill adds that DOJ
must award grants to organizations that provide services for crime victims.

Elder abuse grants and hotline

Attorney general and litigation

Powers of the attorney general

The bill repeals changes made to the powers of the attorney general in 2017
Wisconsin Act 369 relating to the power to compromise or discontinue civil actions
prosecuted by DOJ and the power to compromise and settle actions in cases where
DOJ is defending the state. The bill reestablishes these settlement powers as they
existed under the law before 2017 Wisconsin Act 369 was enacted.

The bill allows the attorney general to compromise or discontinue actions
prosecuted by DOJ 1) when directed by the officer, department, board, or commission
that directed the prosecution or 2) with the approval of the governor when the action
is prosecuted by DOJ on the initiative of the attorney general or at the request of any
individual. The bill eliminates the requirement for approval of a compromise or
discontinuance from a legislative intervenor or JCF. It also eliminates the
requirement for the attorney general to obtain approval of a compromise or
discontinuance by the Joint Committee on Legislative Organization in certain
circumstances before submitting a proposed plan to JCF.

Under the bill, when DOJ is defending the state, the attorney general may
compromise and settle the action as the attorney general determines to be in the best
interest of the state. The bill eliminates the requirement under current law that, in

actions for injunctive relief or if there is a proposed consent decree, the attorney
general must 1) obtain the approval of any legislative intervenor or 2) if there is no
intervenor, submit a proposed plan to JCF and, in certain circumstances, obtain
approval of JCF. The bill also eliminates the requirement for the attorney general
to obtain approval from JCLO in certain circumstances before submitting a proposed
plan of settlement or compromise to JCF.

Gifts and grants and disposition of settlement funds