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110. Page 428, line 7: delete the material beginning with "primary care" and
2ending with "provider," on line 9, and substitute "health care professional".
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6"
(3) Primary providers. Except as provided in sub. (3), a managed care plan
7shall permit each enrollee to select his or her own primary provider from a list of
8participating health care professionals. The list shall be updated on an ongoing basis
9and shall include all of the following:
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(a) A sufficient number of health care professionals who are accepting new
11enrollees.
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(b) A sufficient diversity of health care professionals to adequately meet the
13needs of an enrollee population with varied characteristics, including age, gender,
14race and health status.
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15(4) Specialist providers. (a) A managed care plan shall establish a system
16under which an enrollee with a chronic disease or other special needs may select a
17participating specialist physician as his or her primary provider.
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(b) A managed care plan shall allow all enrollees under the plan to have access
19to specialist physicians on a timely basis when specialty medical care is warranted.
20An enrollee shall be allowed to choose among participating specialist physicians
21when a referral is made for specialty care.
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22(4m) Point-of-service option. A managed care plan shall offer a
23point-of-service option, under which an enrollee may obtain covered services from
24a nonparticipating provider of the enrollee's choice. Under the point-of-service
1option, the enrollee may be required to pay a reasonable portion of the cost of those
2services.".
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5609.23 Drugs and devices. (1) Coverage. (a) A managed care plan shall
6provide coverage of any drug or device that is approved for use by the federal food and
7drug administration and that is determined by a treating participating provider to
8be medically appropriate and necessary for treatment of an enrollee's condition,
9regardless of whether the drug or device is prescribed by the treating participating
10provider for the use for which the drug or device is approved by the federal food and
11drug administration.
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(b) A treating participating provider shall determine the drug therapy that is
13appropriate for his or her patient.
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(c) Prospective review of drug therapy may deny coverage only if any of the
15following apply:
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1. A coverage limitation has been reached with respect to the enrollee.
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2. The enrollee has committed fraud with respect to obtaining the drug.
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18(2) Drug utilization review program. (a) A managed care plan shall establish
19and operate a drug utilization review program. The primary goal of the program
20shall be to enhance quality of care for enrollees by ensuring appropriate drug
21therapy.
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(b) The program under par. (a) shall include all of the following:
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1. Retrospective review of prescription drugs furnished to enrollees.
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12. Ongoing periodic examination of data on outpatient prescription drugs to
2ensure quality therapeutic outcomes for enrollees.
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3. An educational outreach program for physicians, pharmacists and enrollees
4regarding the appropriate use of prescription drugs.
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(c) The program under par. (a) shall utilize all of the following:
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1. Clinically relevant criteria and standards for drug therapy.
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2. Nonproprietary criteria and standards developed and revised through an
8open, professional consensus process.
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3. Interventions that focus on improving therapeutic outcomes.".
