AB43: Bill Text

AB43,1564,24 601.785 Prescription drug affordability review board. (1) Mission. The purpose of the board is to protect state residents, the state, local governments, health plans, health care providers, pharmacies licensed in this state, and other stakeholders of the health care system in this state from the high costs of prescription drug products.

AB43,1564,25 (2) Powers and duties. (a) The board shall do all of the following:

AB43,1565,3 1. Meet in open session at least 4 times per year to review prescription drug product pricing information, except that the chair may cancel or postpone a meeting if there is no business to transact.

AB43,1565,5 2. To the extent practicable, access and assess pricing information for prescription drug products by doing all of the following:

AB43,1565,8 a. Accessing and assessing information from other states by entering into memoranda of understanding with other states to which manufacturers report pricing information.

AB43,1565,9 b. Assessing spending for specific prescription drug products in this state.

AB43,1565,10 c. Accessing other available pricing information.

AB43,1565,11 (b) The board may do any of the following:

AB43,1565,12 1. Promulgate rules for the administration of this subchapter.

AB43,1565,17 2. Enter into a contract with an independent 3rd party for any service necessary to carry out the powers and duties of the board. Unless written permission is granted by the board, any person with whom the board contracts may not release, publish, or otherwise use any information to which the person has access under the contract.

AB43,1565,20 (c) The board shall establish and maintain a website to provide public notices and make meeting materials available under sub. (3) (a) and to disclose conflicts of interest under sub. (4) (d).

AB43,1565,24 (3) Meeting requirements. (a) Pursuant to s. 19.84, the board shall provide public notice of each board meeting at least 2 weeks prior to the meeting and shall make the materials for each meeting publicly available at least one week prior to the meeting.

AB43,1566,3 (b) Notwithstanding s. 19.84 (2), the board shall provide an opportunity for public comment at each open meeting and shall provide the public with the opportunity to provide written comments on pending decisions of the board.

AB43,1566,6 (c) Notwithstanding subch. V of ch. 19, any portion of a meeting of the board concerning proprietary data and information shall be conducted in closed session and shall in all respects remain confidential.

AB43,1566,8 (d) The board may allow expert testimony at any meeting, including when the board meets in closed session.

AB43,1566,12 (4) Conflicts of interest. (a) A member of the board shall recuse himself or herself from a decision by the board relating to a prescription drug product if the member or an immediate family member has received or could receive any of the following:

AB43,1566,14 1. A direct financial benefit deriving from a determination, or a finding of a study or review, by the board relating to the prescription drug product.

AB43,1566,17 2. A financial benefit in excess of $5,000 in a calendar year from any person who owns, manufactures, or provides a prescription drug product to be studied or reviewed by the board.

AB43,1566,21 (b) A conflict of interest under this subsection shall be disclosed by the board when hiring board staff, by the appointing authority when appointing members to the board, and by the board when a member of the board is recused from any decision relating to a review of a prescription drug product.

AB43,1566,25 (c) A conflict of interest under this subsection shall be disclosed no later than 5 days after the conflict is identified, except that, if the conflict is identified within 5 days of an open meeting of the board, the conflict shall be disclosed prior to the meeting.

AB43,1567,4 (d) The board shall disclose a conflict of interest under this subsection on the board's website unless the chair of the board recuses the member from a final decision relating to a review of the prescription drug product. The disclosure shall include the type, nature, and magnitude of the interests of the member involved.

AB43,1567,7 (e) A member of the board or a 3rd-party contractor may not accept any gift or donation of services or property that indicates a potential conflict of interest or has the appearance of biasing the work of the board.

AB43,3045 Section 3045. 601.79 of the statutes is created to read:

AB43,1567,10 601.79 Drug cost affordability review. (1) Identification of drugs. The board shall identify prescription drug products that are any of the following:

AB43,1567,14 (a) A brand name drug or biologic that, as adjusted annually to reflect adjustments to the U.S. consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor, has a launch wholesale acquisition cost of at least $30,000 per year or course of treatment.

AB43,1567,18 (b) A brand name drug or biologic that, as adjusted annually to reflect adjustments to the U.S. consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor, has a wholesale acquisition cost that has increased at least $3,000 during a 12-month period.

AB43,1567,21 (c) A biosimilar that has a launch wholesale acquisition cost that is not at least 15 percent lower than the referenced brand biologic at the time the biosimilar is launched.

AB43,1567,25 (d) A generic drug that has a wholesale acquisition cost, as adjusted annually to reflect adjustments to the U.S. consumer price index for all urban consumers, U.S. city average, as determined by the U.S. department of labor, that meets all of the following conditions:

AB43,1568,6 1. Is at least $100 for a supply lasting a patient for a period of 30 consecutive days based on the recommended dosage approved for labeling by the federal food and drug administration, a supply lasting a patient for a period of fewer than 30 days based on the recommended dosage approved for labeling by the federal food and drug administration, or one unit of the drug if the labeling approved by the federal food and drug administration does not recommend a finite dosage.

AB43,1568,9 2. Increased by at least 200 percent during the preceding 12-month period, as determined by the difference between the resulting wholesale acquisition cost and the average of the wholesale acquisition cost reported over the preceding 12 months.

AB43,1568,12 (e) Other prescription drug products, including drugs to address public health emergencies, that may create affordability challenges for the health care system and patients in this state.

AB43,1568,17 (2) Affordability review. (a) After identifying prescription drug products under sub. (1), the board shall determine whether to conduct an affordability review for each identified prescription drug product by seeking stakeholder input about the prescription drug product and considering the average patient cost share of the prescription drug product.

AB43,1568,23 (b) The information used to conduct an affordability review under par. (a) may include any document and research related to the manufacturer's selection of the introductory price or price increase of the prescription drug product, including life cycle management, net average price in this state, market competition and context, projected revenue, and the estimated value or cost-effectiveness of the prescription drug product.

AB43,1569,3 (c) The failure of a manufacturer to provide the board with information for an affordability review under par. (b) does not affect the authority of the board to conduct the review.

AB43,1569,11 (3) Affordability challenge. When conducting an affordability review of a prescription drug product under sub. (2), the board shall determine whether use of the prescription drug product that is fully consistent with the labeling approved by the federal food and drug administration or standard medical practice has led or will lead to an affordability challenge for the health care system in this state, including high out-of-pocket costs for patients. To the extent practicable, in determining whether a prescription drug product has led or will lead to an affordability challenge, the board shall consider all of the following factors:

AB43,1569,13 (a) The wholesale acquisition cost for the prescription drug product sold in this state.

AB43,1569,17 (b) The average monetary price concession, discount, or rebate the manufacturer provides, or is expected to provide, to health plans in this state as reported by manufacturers and health plans, expressed as a percent of the wholesale acquisition cost for the prescription drug product under review.

AB43,1569,21 (c) The total amount of the price concessions, discounts, and rebates the manufacturer provides to each pharmacy benefit manager for the prescription drug product under review, as reported by the manufacturer and pharmacy benefit manager and expressed as a percent of the wholesale acquisition cost.

AB43,1569,23 (d) The price at which therapeutic alternatives to the prescription drug product have been sold in this state.

AB43,1570,3 (e) The average monetary concession, discount, or rebate the manufacturer provides or is expected to provide to health plan payors and pharmacy benefit managers in this state for therapeutic alternatives to the prescription drug product.

AB43,1570,6 (f) The costs to health plans based on patient access consistent with labeled indications by the federal food and drug administration and recognized standard medical practice.

AB43,1570,8 (g) The impact on patient access resulting from the cost of the prescription drug product relative to insurance benefit design.

AB43,1570,10 (h) The current or expected dollar value of drug-specific patient access programs that are supported by the manufacturer.

AB43,1570,13 (i) The relative financial impacts to health, medical, or social services costs that can be quantified and compared to baseline effects of existing therapeutic alternatives to the prescription drug product.

AB43,1570,15 (j) The average patient copay or other cost sharing for the prescription drug product in this state.

AB43,1570,16 (k) Any information a manufacturer chooses to provide.

AB43,1570,17 (L) Any other factors as determined by the board by rule.

AB43,1570,21 (4) Upper payment limit. (a) If the board determines under sub. (3) that use of a prescription drug product has led or will lead to an affordability challenge, the board shall establish an upper payment limit for the prescription drug product after considering all of the following:

AB43,1570,22 1. The cost of administering the drug.

AB43,1570,23 2. The cost of delivering the drug to consumers.

AB43,1570,24 3. Other relevant administrative costs related to the drug.

AB43,1571,6 (b) For a prescription drug product identified in sub. (1) (b) or (d) 2., the board shall solicit information from the manufacturer regarding the price increase. To the extent 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 shall establish an upper payment limit under par. (a) that is equal to the cost to consumers prior to the price increase.

AB43,1571,10 (c) 1. The upper payment limit established under this subsection shall apply to all purchases and payor reimbursements of the prescription drug product dispensed or administered to individuals in this state in person, by mail, or by other means.

AB43,1571,21 2. Notwithstanding subd. 1., while state-sponsored and state-regulated health plans and health programs shall limit drug reimbursements and drug payment to no more than the upper payment limit established under this subsection, a plan subject to the Employee Retirement Income Security Act of 1974 or Part D of Medicare under 42 USC 1395w-101 et seq. may choose to reimburse more than the upper payment limit. A provider who dispenses and administers a prescription drug product in this state to an individual in this state may not bill a payor more than the upper payment limit to the patient regardless of whether a plan subject to the Employee Retirement Income Security Act of 1974 or Part D of Medicare under 42 USC 1395w-101 et seq. chooses to reimburse the provider above the upper payment limit.

AB43,1571,23 (5) Public inspection. Information submitted to the board under this section shall be open to public inspection only as provided under ss. 19.31 to 19.39.

AB43,1572,2 (6) No prohibition on marketing. Nothing in this section may be construed to prevent a manufacturer from marketing a prescription drug product approved by the federal food and drug administration while the prescription drug product is under review by the board.

AB43,1572,7 (7) Appeals. A person aggrieved by a decision of the board may request an appeal of the decision no later than 30 days after the board makes the determination. The board shall hear the appeal and make a final decision no later than 60 days after the appeal is requested. A person aggrieved by a final decision of the board may petition for judicial review in a court of competent jurisdiction.

AB43,3046 Section 3046 . 601.83 (1) (a) of the statutes is amended to read:

AB43,1572,21 601.83 (1) (a) The commissioner shall administer a state-based reinsurance program known as the healthcare stability plan in accordance with the specific terms and conditions approved by the federal department of health and human services dated July 29, 2018. Before December 31, 2023, the commissioner may not request from the federal department of health and human services a modification, suspension, withdrawal, or termination of the waiver under 42 USC 18052 under which the healthcare stability plan under this subchapter operates unless legislation has been enacted specifically directing the modification, suspension, withdrawal, or termination. Before December 31, 2023, the commissioner may request renewal, without substantive change, of the waiver under 42 USC 18052 under which the health care stability plan operates in accordance with s. 20.940 (4) unless legislation has been enacted that is contrary to such a renewal request. The commissioner shall comply with applicable timing in and requirements of s. 20.940.

AB43,3047 Section 3047. 601.83 (1) (h) of the statutes is renumbered 601.83 (1) (h) (intro.) and amended to read:

AB43,1573,4 601.83 (1) (h) (intro.) In 2019 and in each subsequent year Unless the joint committee on finance under s. 13.10 increases the amount upon request by the commissioner, the commissioner may expend no more than $200,000,000 the following amounts from all revenue sources for the healthcare stability plan under this section, unless the joint committee on finance under s. 13.10 has increased this amount upon request by the commissioner.:

AB43,1573,8 (he) The commissioner shall ensure that sufficient funds are available for the healthcare stability plan under this section to operate as described in the approval of the federal department of health and human services dated July 29, 2018, and in any waiver extension approvals.

AB43,3048 Section 3048. 601.83 (1) (h) 1. and 3. of the statutes are created to read:

AB43,1573,10 601.83 (1) (h) 1. In 2019, 2020, and 2021, $200,000,000.

AB43,1573,19 3. In 2025 and in each year thereafter, the maximum expenditure amount for the previous year, adjusted to reflect the percentage increase, if any, in the consumer price index for all urban consumers, U.S. city average, for the medical care group, as determined by the U.S. department of labor, for the 12-month period ending on December 31 of the year before the year in which the amount is determined. The commissioner shall determine the annual adjustment amount for a particular year in January of the previous year. The commissioner shall publish the new maximum expenditure amount under this subdivision each year in the Wisconsin Administrative Register.

AB43,3049 Section 3049. 601.83 (1) (hm) of the statutes is renumbered 601.83 (1) (h) 2. and amended to read:

AB43,1573,24 601.83 (1) (h) 2. Notwithstanding par. (h), in In 2022 and in each year thereafter, the commissioner may expend from all revenue sources , 2023, and 2024, $230,000,000 or less for the healthcare stability plan under this section.

AB43,3050 Section 3050 . 609.045 of the statutes is created to read:

AB43,1574,2 609.045 Balance billing; emergency medical services. (1) Definitions. In this section:

AB43,1574,3 (a) “Emergency medical condition” means all of the following:

AB43,1574,7 1. A medical condition, including a mental health condition or substance use disorder condition, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

AB43,1574,9 a. Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.

AB43,1574,10 b. Serious impairment of bodily function.

AB43,1574,11 c. Serious dysfunction of any bodily organ or part.

AB43,1574,15 2. With respect to a pregnant woman who is having contractions, a medical condition for which there is inadequate time to safely transfer the pregnant woman to another hospital before delivery or for which the transfer may pose a threat to the health or safety of the pregnant woman or the unborn child.

AB43,1574,18 (b) “Emergency medical services,” with respect to an emergency medical condition, has the meaning given for “emergency services” in 42 USC 300gg-111 (a) (3) (C).

AB43,1574,20 (c) “Independent freestanding emergency department" has the meaning given in 42 USC 300gg-111 (a) (3) (D).

AB43,1574,22 (d) “Out-of-network rate” has the meaning given by the commissioner by rule or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (K).

AB43,1575,2 (e) “Preferred provider plan,” notwithstanding s. 609.01 (4), includes only any preferred provider plan, as defined in s. 609.01 (4), that has a network of participating providers and imposes on enrollees different requirements for using providers that are not participating providers.

AB43,1575,4 (f) “Recognized amount” has the meaning given by the commissioner by rule or, in the absence of such rule, the meaning given in 42 USC 300gg-111 (a) (3) (H).

AB43,1575,8 (g) “Self-insured governmental plan” means a self-insured health plan of the state or a county, city, village, town, or school district that has a network of participating providers and imposes on enrollees in the self-insured health plan different requirements for using providers that are not participating providers.

AB43,1575,11 (h) “Terminated” means the expiration or nonrenewal of a contract. “Terminated” does not include a termination of a contract for failure to meet applicable quality standards or for fraud.

AB43,1575,16 (2) Emergency medical services. A defined network plan, preferred provider plan, or self-insured governmental plan that covers any benefits or services provided in an emergency department of a hospital or emergency medical services provided in an independent freestanding emergency department shall cover emergency medical services in accordance with all of the following:

AB43,1575,17 (a) The plan may not require a prior authorization determination.

AB43,1575,20 (b) The plan may not deny coverage on the basis of whether or not the health care provider providing the services is a participating provider or participating emergency facility.

AB43,1575,23 (c) If the emergency medical services are provided to an enrollee by a provider or in a facility that is not a participating provider or participating facility, the plan complies with all of the following:

AB43,1576,2 1. The emergency medical services are covered without imposing on an enrollee a requirement for prior authorization or any coverage limitation that is more restrictive than requirements or limitations that apply to emergency medical services provided by participating providers or in participating facilities.

AB43,1576,6 2. Any cost-sharing requirement imposed on an enrollee for the emergency medical services is no greater than the requirements that would apply if the emergency medical services were provided by a participating provider or in a participating facility.