AB68-ASA2-AA2,94,2
15. The individual has not received insulin under an urgent need safety net
2program within the previous 12 months, except as allowed under par. (d).
AB68-ASA2-AA2,94,63
(c)
Provision of insulin under an urgent need safety net program. 1. In order
4to receive insulin under an urgent need safety net program, an individual who meets
5the eligibility requirements under par. (b) shall provide a pharmacy with all of the
6following:
AB68-ASA2-AA2,94,107
a. A completed application, on a form prescribed by the commissioner that shall
8include an attestation by the individual, or the individual's parent or legal guardian
9if the individual is under the age of 18, that the individual meets all of the eligibility
10requirements under par. (b).
AB68-ASA2-AA2,94,1111
b. A valid insulin prescription.
AB68-ASA2-AA2,94,1412
c. A valid Wisconsin driver's license or state identification card. If the
13individual is under the age of 18, the individual's parent or legal guardian shall meet
14this requirement.
AB68-ASA2-AA2,94,2215
2. Upon receipt of the information described in subd. 1. a. to c., the pharmacist
16shall dispense a 30-day supply of the prescribed insulin to the individual. The
17pharmacy shall also provide the individual with the information sheet described in
18sub. (8) (b) 2. and the list of navigators described in sub. (8) (c). The pharmacy may
19collect a copayment, not to exceed $35, from the individual to cover the pharmacy's
20costs of processing and dispensing the insulin. The pharmacy shall notify the health
21care practitioner who issued the prescription no later than 72 hours after the insulin
22is dispensed.
AB68-ASA2-AA2,95,523
3. A pharmacy that dispenses insulin under subd. 2. may submit to the
24manufacturer, or the manufacturer's vendor, a claim for payment that is in
25accordance with the national council for prescription drug programs' standards for
1electronic claims processing, except that no claim may be submitted if the
2manufacturer agrees to send the pharmacy a replacement of the same insulin in the
3amount dispensed. If the pharmacy submits an electronic claim, the manufacturer
4or vendor shall reimburse the pharmacy in an amount that covers the pharmacy's
5acquisition cost.
AB68-ASA2-AA2,95,76
4. A pharmacy that dispenses insulin under subd. 2. shall retain a copy of the
7application form described in subd. 1. a.
AB68-ASA2-AA2,95,148
(d)
Eligibility of certain individuals. An individual who has applied for public
9assistance under ch. 49 but for whom a determination of eligibility has not been made
10or whose coverage has not become effective or an individual who has an appeal
11pending under sub. (3) c. 4. may access insulin under this subsection if the individual
12is in urgent need of insulin. To access a 30-day supply of insulin, the individual shall
13attest to the pharmacy that the individual is described in this paragraph and comply
14with par. (c) 1.
AB68-ASA2-AA2,95,19
15(3) Patient assistance program. (a)
Establishment of program. No later than
16July 1, 2022, each manufacturer shall establish a patient assistance program to
17make insulin available in accordance with this subsection to individuals who meet
18the eligibility requirements under par. (b). Under the program, the manufacturer
19shall do all of the following:
AB68-ASA2-AA2,95,2220
1. Provide the commissioner with information regarding the program,
21including contact information for individuals to call for assistance in accessing the
22program.
AB68-ASA2-AA2,95,2423
2. Provide a hotline for individuals to call or access between 8 a.m. and 10 p.m.
24on weekdays and between 10 a.m. and 6 p.m. on Saturdays.
AB68-ASA2-AA2,96,2
13. List the eligibility requirements under par. (b) on the manufacturer's
2Internet site.
AB68-ASA2-AA2,96,63
4. Maintain the privacy of all information received from an individual applying
4for or participating in the program and not sell, share, or disseminate the
5information unless required under this section or authorized, in writing, by the
6individual.
AB68-ASA2-AA2,96,87
(b)
Eligible individual. An individual shall be eligible to receive insulin under
8a patient assistance program if all of the following conditions are met:
AB68-ASA2-AA2,96,99
1. The individual is a resident of this state.
AB68-ASA2-AA2,96,1210
2. The individual, or the individual's parent or legal guardian if the individual
11is under the age of 18, has a valid Wisconsin driver's license or state identification
12card.
AB68-ASA2-AA2,96,1313
3. The individual has a valid insulin prescription.
AB68-ASA2-AA2,96,1614
4. The family income of the individual does not exceed 400 percent of the
15poverty line as defined and revised annually under
42 USC 9902 (2) for a family the
16size of the individual's family,
AB68-ASA2-AA2,96,1717
5. The individual is not receiving public assistance under ch. 49.
AB68-ASA2-AA2,96,2318
6. The individual is not eligible to receive health care through a federally
19funded program or receive prescription drug benefits through the U.S. department
20of veterans affairs, except that this subdivision does not apply to an individual who
21is enrolled in a policy under Part D of Medicare under
42 USC 1395w-101 et seq. if
22the individual has spent at least $1,000 on prescription drugs in the current calendar
23year.
AB68-ASA2-AA2,97,324
7. The individual is not enrolled in prescription drug coverage through an
25individual or group health plan that limits the total cost sharing amount, including
1copayments, deductibles, and coinsurance, that an enrollee is required to pay for a
230-day supply of insulin to no more than $75, regardless of the type or amount of
3insulin needed.
AB68-ASA2-AA2,97,124
(c)
Application for patient assistance program. 1. An individual may apply to
5participate in a patient assistance program by filing an application with the
6manufacturer who established the program, the individual's health care practitioner
7if the practitioner participates in the program, or a navigator included on the list
8under sub. (8) (c).
A health care practitioner or navigator shall immediately submit
9the application to the manufacturer. Upon receipt of an application, the
10manufacturer shall determine the individual's eligibility under par. (b) and, except
11as provided in subd. 2., notify the individual of the determination no later than 10
12days after receipt of the application.
AB68-ASA2-AA2,97,1813
2. If necessary to determine the individual's eligibility under par. (b), the
14manufacturer may request additional information from an individual who has filed
15an application under subd. 1. no later than 5 days after receipt of the application.
16Upon receipt of the additional information, the manufacturer shall determine the
17individual's eligibility under par. (b) and notify the individual of the determination
18no later than 3 days after receipt of the requested information.
AB68-ASA2-AA2,97,2419
3. Except as provided in subd. 5., if the manufacturer determines under subd.
201. or 2. that the individual is eligible for the patient assistance program, the
21manufacturer shall provide the individual with a statement of eligibility. The
22statement of eligibility shall be valid for 12 months and may be renewed upon a
23determination by the manufacturer that the individual continues to meet the
24eligibility requirements of par. (b).
AB68-ASA2-AA2,98,11
14. If the manufacturer determines under subd. 1. or 2. that the individual is not
2eligible for the patient assistance program, the manufacturer shall provide the
3reason for the determination in the notification under subd. 1. or 2. The individual
4may appeal the determination by filing an appeal with the commissioner that shall
5include all of the information provided to the manufacturer under subds. 1. and 2.
6The commissioner shall establish procedures for deciding appeals under this
7subdivision. The commissioner shall issue a decision no later than 10 days after the
8appeal is filed, and the commissioner's decision shall be final. If the commissioner
9determines that the individual meets the eligibility requirements under par. (b), the
10manufacturer shall provide the individual with the statement of eligibility described
11in subd. 3.
AB68-ASA2-AA2,98,2012
5. In the case of an individual who has prescription drug coverage through an
13individual or group health plan,
if the manufacturer determines under subd. 1. or 2.
14that the individual is eligible for the patient assistance program but also determines
15that the individual's insulin needs are better addressed through the use of the
16manufacturer's copayment assistance program rather than the patient assistance
17program, the manufacturer shall inform the individual of the determination and
18provide the individual with the necessary coupons to submit to a pharmacy. The
19individual may not be required to pay more than the copayment amount specified in
20par. (d) 2.
AB68-ASA2-AA2,99,221
(d)
Provision of insulin under a patient assistance program. 1. Upon receipt
22from an individual of the eligibility statement described in par. (c) 3. and a valid
23insulin prescription, a pharmacy shall submit an order containing the name of the
24insulin and daily dosage amount to the manufacturer. The pharmacy shall include
25with the order the pharmacy's name, shipping address, office telephone number, fax
1number, electronic mail address, and contact name, as well as any days or times
2when deliveries are not accepted by the pharmacy.
AB68-ASA2-AA2,99,113
2. Upon receipt of an order meeting the requirements under subd. 1., the
4manufacturer shall send the pharmacy a 90-day supply of insulin, or lesser amount
5if requested in the order, at no charge to the individual or pharmacy. The pharmacy
6shall dispense the insulin to the individual associated with the order. The insulin
7shall be dispensed at no charge to the individual, except that the pharmacy may
8collect a copayment from the individual to cover the pharmacy's costs for processing
9and dispensing in an amount not to exceed $50 for each 90-day supply of insulin.
10The pharmacy may not seek reimbursement from the manufacturer or a 3rd-party
11payer.
AB68-ASA2-AA2,99,1412
3. The pharmacy may submit a reorder to the manufacturer if the individual's
13eligibility statement described in par. (c) 3. has not expired. The reorder shall be
14treated as an order for purposes of subd. 2.
AB68-ASA2-AA2,99,1715
4. Notwithstanding subds. 2. and 3., a manufacturer may send the insulin
16directly to the individual if the manufacturer provides a mail-order service option,
17in which case the pharmacy may not collect a copayment from the individual.
AB68-ASA2-AA2,99,20
18(4) Exceptions. (a) This section does not apply to a manufacturer who shows
19to the commissioner's satisfaction that the manufacturer's annual gross revenue
20from insulin sales in this state does not exceed $2,000,000.
AB68-ASA2-AA2,99,2521
(b) A manufacturer may not be required to make an insulin product available
22under sub. (2) or (3) if the wholesale acquisition cost of the insulin product does not
23exceed $8, as adjusted annually based on the U.S. consumer price index for all urban
24consumers, U.S. city average, per milliliter or the applicable national council for
25prescription drug programs' plan billing unit.
AB68-ASA2-AA2,100,3
1(5) Confidentiality. All medical information solicited or obtained by any
2person under this section shall be subject to the applicable provisions of state law
3relating to confidentiality of medical information, including s. 610.70.
AB68-ASA2-AA2,100,9
4(6) Reimbursement prohibition. No person, including a manufacturer,
5pharmacy, pharmacist, or 3rd-party administrator, as part of participating in an
6urgent need safety net program or patient assistance program may request or seek,
7or cause another person to request or seek, any reimbursement or other
8compensation for which payment may be made in whole or in part under a federal
9health care program, as defined in
42 USC 1320a-7b (f).
AB68-ASA2-AA2,100,12
10(7) Reports. (a) Annually, no later than March 1, each manufacturer shall
11report to the commissioner all of the following information for the previous calendar
12year:
AB68-ASA2-AA2,100,1413
1. The number of individuals who received insulin under the manufacturer's
14urgent need safety net program.
AB68-ASA2-AA2,100,1715
2. The number of individuals who sought assistance under the manufacturer's
16patient assistance program and the number of individuals who were determined to
17be ineligible under sub. (3) (c) 4.
AB68-ASA2-AA2,100,1918
3. The wholesale acquisition cost of the insulin provided by the manufacturer
19through the urgent need safety net program and patient assistance program.
AB68-ASA2-AA2,100,2320
(b) Annually, no later than April 1, the commissioner shall submit to the
21governor and the chief clerk of each house of the legislature, for distribution to the
22legislature under s. 13.172 (2), a report on the urgent need safety net programs and
23patient assistance programs that includes all of the following:
AB68-ASA2-AA2,100,2424
1. The information provided to the commissioner under par. (a).
AB68-ASA2-AA2,101,2
12. The penalties assessed under sub. (9) during the previous calendar year,
2including the name of the manufacturer and amount of the penalty.
AB68-ASA2-AA2,101,7
3(8) Additional responsibilities of commissioner. (a)
Application form. The
4commissioner shall make the application form described in sub. (2) (c) 1. a. available
5on the office's Internet site and shall make the form available to pharmacies and
6health care providers who prescribe or dispense insulin, hospital emergency
7departments, urgent care clinics, and community health clinics.
AB68-ASA2-AA2,101,108
(b)
Public outreach. 1. The commissioner shall conduct public outreach to
9create awareness of the urgent need safety net programs and patient assistance
10programs.
AB68-ASA2-AA2,101,1211
2. The commissioner shall develop and make available on the office's Internet
12site an information sheet that contains all of the following information:
AB68-ASA2-AA2,101,1413
a. A description of how to access insulin through an urgent need safety net
14program.
AB68-ASA2-AA2,101,1515
b. A description of how to access insulin through a patient assistance program.
AB68-ASA2-AA2,101,1716
c. Information on how to contact a navigator for assistance in accessing insulin
17through an urgent need safety net program or patient assistance program.
AB68-ASA2-AA2,101,1918
d. Information on how to contact the commissioner if a manufacturer
19determines that an individual is not eligible for a patient assistance program.
AB68-ASA2-AA2,101,2120
e. A notification that an individual may contact the commissioner for more
21information or assistance in accessing ongoing affordable insulin options.
AB68-ASA2-AA2,102,322
(c)
Navigators. The commissioner shall develop a training program to provide
23navigators with information and the resources necessary to assist individuals in
24accessing appropriate long-term insulin options. The commissioner shall compile
25a list of navigators who have completed the training program and are available to
1assist individuals in accessing affordable insulin coverage options. The list shall be
2made available on the office's Internet site and to pharmacies and health care
3practitioners who dispense and prescribe insulin.
AB68-ASA2-AA2,102,94
(d)
Satisfaction surveys. 1. The commissioner shall develop and conduct a
5satisfaction survey of individuals who have accessed insulin through urgent need
6safety net programs and patient assistance programs. The survey shall ask whether
7the individual is still in need of a long-term solution for affordable insulin and shall
8include questions about the individual's satisfaction with all of the following, if
9applicable:
AB68-ASA2-AA2,102,1010
a. Accessibility to urgent-need insulin.
AB68-ASA2-AA2,102,1211
b. Adequacy of the information sheet and list of navigators received from the
12pharmacy.
AB68-ASA2-AA2,102,1313
c. Helpfulness of a navigator.
AB68-ASA2-AA2,102,1514
d. Ease of access in applying for a patient assistance program and receiving
15insulin from the pharmacy under the program.
AB68-ASA2-AA2,102,1916
2. The commissioner shall develop and conduct a satisfaction survey of
17pharmacies that have dispensed insulin through urgent need safety net programs
18and patient assistance programs. The survey shall include questions about the
19pharmacy's satisfaction with all of the following, if applicable:
AB68-ASA2-AA2,102,2120
a. Timeliness of reimbursement from manufacturers for insulin dispensed by
21the pharmacy under urgent need safety net programs.
AB68-ASA2-AA2,102,2222
b. Ease in submitting insulin orders to manufacturers.
AB68-ASA2-AA2,102,2323
c. Timeliness of receiving insulin orders from manufacturers.
AB68-ASA2-AA2,102,2524
3. The commissioner may contract with a nonprofit entity to develop and
25conduct the surveys under subds. 1. and 2. and to evaluate the survey results.
AB68-ASA2-AA2,103,3
14. No later than July 1, 2024, the commissioner shall submit to the governor
2and the chief clerk of each house of the legislature, for distribution to the legislature
3under s. 13.172 (2), a report on the results of the surveys under subds. 1. and 2.
AB68-ASA2-AA2,103,8
4(9) Penalty. A manufacturer that fails to comply with this section may be
5assessed a penalty of up to $200,000 per month of noncompliance, with the maximum
6penalty increasing to $400,000 per month if the manufacturer continues to be in
7noncompliance after 6 months and increasing to $600,000 per month if the
8manufacturer continues to be in noncompliance after one year.
AB68-ASA2-AA2,103,11
10632.869 Reimbursement to federal drug pricing program participants.
11 (
1) In this section:
AB68-ASA2-AA2,103,1512
(a) “Covered entity” means an entity described in
42 USC 256b (a) (4) (A), (D),
13(E), (J), or (N) that participates in the federal drug pricing program under
42 USC
14256b, a pharmacy of the entity, or a pharmacy contracted with the entity to dispense
15drugs purchased through the federal drug pricing program under
42 USC 256b.
AB68-ASA2-AA2,103,1616
(b) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
AB68-ASA2-AA2,103,18
17(2) Any person, including a pharmacy benefit manager and 3rd-party payer,
18may not do any of the following:
AB68-ASA2-AA2,103,2119
(a) Reimburse a covered entity for a drug that is subject to an agreement under
2042 USC 256b at a rate lower than that paid for the same drug to pharmacies that are
21not covered entities and are similar in prescription volume to the covered entity.
AB68-ASA2-AA2,103,2422
(b) Assess a covered entity any fee, charge back, or other adjustment on the
23basis of the covered entity's participation in the federal drug pricing program under
2442 USC 256b.
AB68-ASA2-AA2,104,1
1632.871 Telehealth services. (1) Definitions. In this section:
AB68-ASA2-AA2,104,22
(a) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
AB68-ASA2-AA2,104,33
(b) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
AB68-ASA2-AA2,104,94
(c) “Telehealth" means a practice of health care delivery, diagnosis,
5consultation, treatment, or transfer of medically relevant data by means of audio,
6video, or data communications that are used either during a patient visit or a
7consultation or are used to transfer medically relevant data about a patient.
8“Telehealth" does not include communications delivered solely by audio-only
9telephone, facsimile machine, or e-mail unless specified otherwise by rule.
AB68-ASA2-AA2,104,16
10(2) Coverage denial prohibited. No disability insurance policy or self-insured
11health plan may deny coverage for a treatment or service provided through
12telehealth on the basis that the treatment or service is provided through telehealth
13if that treatment or service is covered by the policy or plan when provided in person.
14A disability insurance policy or self-insured health plan may limit coverage of
15treatments or services provided through telehealth to those treatments or services
16that are medically necessary.
AB68-ASA2-AA2,104,20
17(3) Certain limitations on telehealth prohibited. A disability insurance
18policy or self-insured health plan may not subject a treatment or service provided
19through telehealth for which coverage is required under sub. (2) to any of the
20following:
AB68-ASA2-AA2,104,2221
(a) Any greater deductible, copayment, or coinsurance amount than would be
22applicable if the treatment or service is provided in person.
AB68-ASA2-AA2,104,2523
(b) Any policy or calendar year or lifetime benefit limit or other maximum
24limitation that is not imposed on other treatments or services covered by the plan
25that are not provided through telehealth.
AB68-ASA2-AA2,105,2
1(c) Prior authorization requirements that are not required for the same
2treatment or service when provided in person.
AB68-ASA2-AA2,105,33
(d) Unique location requirements.
AB68-ASA2-AA2,105,8
4(4) Disclosure of coverage of certain telehealth services. A disability
5insurance policy or self-insured health plan that covers a telehealth treatment or
6service that has no equivalent in-person treatment or service, such as remote patient
7monitoring, shall specify in policy or plan materials the coverage of that telehealth
8treatment or service.
AB68-ASA2-AA2,105,1010
632.895
(6) (title)
Equipment and supplies for treatment of diabetes; insulin.
AB68-ASA2-AA2,412zj
11Section 412zj. 632.895 (6) of the statutes is renumbered 632.895 (6) (a) and
12amended to read:
AB68-ASA2-AA2,105,2313
632.895
(6) (a) Every disability insurance policy
which that provides coverage
14of expenses incurred for treatment of diabetes shall provide coverage for expenses
15incurred by the installation and use of an insulin infusion pump, coverage for all
16other equipment and supplies, including insulin or any other prescription
17medication, used in the treatment of diabetes, and coverage of diabetic
18self-management education programs.
Coverage
Except as provided in par. (b),
19coverage required under this subsection shall be subject to the same exclusions,
20limitations, deductibles, and coinsurance provisions of the policy as other covered
21expenses, except that insulin infusion pump coverage may be limited to the purchase
22of one pump per year and the insurer may require the insured to use a pump for 30
23days before purchase.
AB68-ASA2-AA2,105,2525
632.895
(6) (b) 1. In this paragraph:
AB68-ASA2-AA2,106,2
1a. “Cost sharing” means the total of any deductible, copayment, or coinsurance
2amounts imposed on a person covered under a policy or plan.