49.686(3)(c)
(c) Has a prescription issued by a physician for AZT, for pentamidine or for a drug approved for reimbursement under
sub. (4) (c).
49.686(3)(d)
(d) Has applied for coverage under and has been denied eligibility for medical assistance within 12 months prior to application for reimbursement under
sub. (2).
49.686(3)(e)
(e) Has no insurance coverage for AZT, the drug pentamidine or any drug approved for reimbursement under
sub. (4) (c) or, if he or she has insurance coverage, the coverage is inadequate to pay the full cost of the individual's prescribed dosage of AZT, the drug pentamidine or any drug approved for reimbursement under
sub. (4) (c).
49.686(3)(f)
(f) Is an individual whose annual gross household income is at or below 200% of the poverty line and, if funding is available under
s. 20.435 (1) (m) or
(5) (i), is an individual whose annual gross household income is above 200% and at or below 300% of the poverty line.
49.686(4)
(4) Departmental duties. The department shall do all of the following:
49.686(4)(a)
(a) Determine the eligibility of individuals applying for reimbursement, or a supplement to the reimbursement, of the costs of AZT or the drug pentamidine.
49.686(4)(b)
(b) Within the limits of
sub. (5) and of the funds specified under
sub. (2) and under a schedule that the department shall establish based on the ability of individuals to pay, reimburse or supplement the reimbursement of the eligible individuals.
49.686(4)(c)
(c) After consulting with individuals, including those not employed by the department, with expertise in issues relative to drugs for the treatment of HIV infection and AIDS, determine which, if any, drugs that are cost-effective alternatives to AZT and pentamidine may also have costs reimbursed under this section.
49.686(5)
(5) Reimbursement limitation. Reimbursement may not be made under this section for any portion of the costs of AZT, the drug pentamidine or any drug approved for reimbursement under
sub. (4) (c) which are payable by an insurer, as defined in
s. 600.03 (27).
49.687
49.687
Disease aids; patient requirements; rebate agreements; cost containment. 49.687(1)
(1) The department shall promulgate rules that require a person who is eligible for benefits under
s. 49.68,
49.683, or
49.685 and whose estimated total family income for the current year is at or above 200% of the poverty line to obligate or expend specified portions of the income for medical care for treatment of kidney disease, cystic fibrosis, or hemophilia before receiving benefits under
s. 49.68,
49.683, or
49.685. The rules shall require a person to pay 0.50% of his or her total family income for the cost of medical treatment covered under
s. 49.68,
49.683, or
49.685 if that income is from 200% to 250% of the federal poverty line, 0.75% if that income is more than 250% but not more than 275% of the federal poverty line, 1% if that income is more than 275% but not more than 300% of the federal poverty line, 1.25% if that income is more than 300% but not more than 325% of the federal poverty line, 2% if that income is more than 325% but not more than 350% of the federal poverty line, 2.75% if that income is more than 350% but not more than 375% of the federal poverty line, 3.5% if that income is more than 375% but not more than 400% of the federal poverty line, and 4.5% if that income is more than 400% of the federal poverty line.
49.687(1m)(a)(a) A person is not eligible to receive benefits under
s. 49.68 or
49.683 unless before the person applies for benefits under
s. 49.68 or
49.683, the person first applies for benefits under all other health care coverage programs specified by the department by rule for which the person reasonably may be eligible.
49.687(1m)(b)
(b) The department shall promulgate rules that specify other health care coverage programs for which a person must apply before applying for benefits under
s. 49.685. The department may waive the requirement under this paragraph for an applicant who requests a waiver for religious reasons.
49.687(1m)(c)
(c) Using the procedure under
s. 227.24, the department may promulgate rules under
par. (b) for the period before the effective date of any permanent rules promulgated under
par. (b), but not to exceed the period authorized under
s. 227.24 (1) (c) and
(2). Notwithstanding
s. 227.24 (1) (a),
(2) (b), and
(3), the department is not required to provide evidence that promulgating a rule under
par. (b) as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to make a finding of emergency for promulgating a rule under
par. (b) as an emergency rule.
49.687(2)
(2) The department shall develop and implement a sliding scale of patient liability for kidney disease aid under
s. 49.68, cystic fibrosis aid under
s. 49.683, and hemophilia treatment under
s. 49.685, based on the patient's ability to pay for treatment. The department shall continuously review the sliding scale for patient liability and revise it as needed to ensure that the amounts budgeted under
s. 20.435 (4) (e) and
(je) are sufficient to cover treatment costs.
49.687(2m)
(2m) If a pharmacy directly bills the department or an entity with which the department contracts for a drug supplied to a person receiving benefits under
s. 49.68,
49.683, or
49.685 and prescribed for treatment covered under
s. 49.68,
49.683, or
49.685, the person shall pay a $7.50 copayment amount for each such generic drug and a $15 copayment amount for each such brand name drug.
49.687(3)
(3) The department or an entity with which the department contracts shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department or entity that is modeled on the rebate agreement specified under
42 USC 1396r-8. The department or entity may enter into a rebate agreement under this subsection that shall include all of the following as requirements:
49.687(3)(a)
(a) That, as a condition of coverage for prescription drugs of a manufacturer under
s. 49.68,
49.683, or
49.685, the manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons who meet eligibility criteria under
s. 49.68,
49.683, or
49.685, to the secretary of administration to be credited to the appropriation under
s. 20.435 (4) (je), each calendar quarter or according to a schedule established by the department.
49.687(4)
(4) The department may adopt managed care methods of cost containment for the programs under
ss. 49.68,
49.683, and
49.685.
49.687 Cross-reference
Cross Reference: See also ch.
HFS 154, Wis. adm. code.
49.688
49.688
Prescription drug assistance for elderly persons. 49.688(1)(b)
(b) "Poverty line" means the nonfarm federal poverty line for the continental United States, as defined by the federal department of labor under
42 USC 9902 (2).
49.688(1)(c)
(c) "Prescription drug" means a prescription drug, as defined in
s. 450.01 (20), that is included in the drugs specified under
s. 49.46 (2) (b) 6. h. and that is manufactured by a drug manufacturer that enters into a rebate agreement in force under
sub. (6).
49.688(1)(e)
(e) "Program payment rate" means the rate of payment made for the identical drug specified under
s. 49.46 (2) (b) 6. h., plus 5%, plus a dispensing fee that is equal to the dispensing fee permitted to be charged for prescription drugs for which coverage is provided under
s. 49.46 (2) (b) 6. h.
49.688(2)(a)(a) A person to whom all of the following applies is eligible to purchase a prescription drug for the amounts specified in
sub. (5) (a) 1. and
2.:
49.688(2)(a)3.
3. The person is not a recipient of medical assistance or, as a recipient, does not receive prescription drug coverage.
49.688(2)(a)4.
4. The person's annual household income, as determined by the department, does not exceed 240% of the federal poverty line for a family the size of the person's eligible family.
49.688(2)(b)
(b) A person to whom
par. (a) 1. to
3. and
5. applies, but whose annual household income, as determined by the department, exceeds 240% of the federal poverty line for a family the size of the persons' eligible family, is eligible to purchase a prescription drug at the amounts specified in
sub. (5) (a) 4. only during the remaining amount of any 12-month period in which the person has first paid the annual deductible specified in
sub. (3) (b) 2. a. in purchasing prescription drugs at the retail price and has then paid the annual deductible specified in
sub. (3) (b) 2. b.
49.688(3)
(3) Program participants shall pay all of the following:
49.688(3)(a)
(a) For each 12-month benefit period, a program enrollment fee of $30.
49.688(3)(b)1.1. For each 12-month benefit period, for a person specified in
sub. (2) (a), a deductible for prescription drugs that is based on the percentage that a person's annual household income, as determined by the department, is of the federal poverty line for a family the size of the person's eligible family, as follows:
49.688(3)(b)2.
2. For each 12-month benefit period, for a person specified in
sub. (2) (b), a deductible for prescription drugs that equals all of the following:
49.688(3)(b)2.a.
a. The difference between the person's annual household income and 240% of the federal poverty line for a family the size of the person's eligible family.
49.688(3)(c)
(c) After payment of any applicable deductible under
par. (b), all of the following:
49.688(3)(c)1.
1. A copayment of $5 for each prescription drug that bears only a generic name.
49.688(3)(c)2.
2. A copayment of $15 for each prescription drug that does not bear only a generic name.
49.688(3)(d)
(d) Notwithstanding
s. 49.002, if a person who is eligible under this section has other available coverage for payment of a prescription drug, this section applies only to costs for prescription drugs for the person that are not covered under the person's other available coverage.
49.688(4)
(4) The department shall devise and distribute a form for application for the program under
sub. (2), shall determine eligibility for each 12-month benefit period of applicants and shall issue to eligible persons a prescription drug card for use in purchasing prescription drugs, as specified in
sub. (5). The department shall promulgate rules that specify the criteria to be used to determine household income under
sub. (2) (a) 4. and
(b) and
(3) (b) 1.
49.688(5)(a)(a) Beginning on September 1, 2002, except as provided in
sub. (7) (b), as a condition of participation by a pharmacy or pharmacist in the program under
s. 49.45,
49.46, or
49.47, the pharmacy or pharmacist may not charge a person who presents a valid prescription order and a card indicating that he or she meets eligibility requirements under
sub. (2) an amount for a prescription drug under the order that exceeds the following:
49.688(5)(a)2.
2. After any applicable deductible under
subd. 1. is charged, the copayment, as applicable, that is specified in
sub. (3) (c) 1. or
2. No dispensing fee may be charged to a person under this subdivision.
49.688(5)(a)4.
4. After the deductible under
subd. 3. is charged, the copayment, as applicable, that is specified in
sub. (3) (c) 1. or
2. No dispensing fee may be charged to a person under this subdivision.
49.688(5)(b)
(b) The department shall calculate and transmit to pharmacies and pharmacists that are certified providers of medical assistance amounts that may be used in calculating charges under
par. (a). The department shall periodically update this information and transmit the updated amounts to pharmacies and pharmacists.
49.688(6)
(6) The department, or an entity with which the department contracts, shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department or entity that is modeled on the rebate agreement specified under
42 USC 1396r-8. A rebate agreement under this subsection shall include all of the following as requirements:
49.688(6)(a)
(a) That, except as provided in
sub. (7) (b), the manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons who meet criteria under
sub. (2) (a) and persons who meet criteria under
sub. (2) (b) and have paid the deductible under
sub. (3) (b) 2. a., to the secretary of administration to be credited to the appropriation account under
s. 20.435 (4) (j), each calendar quarter or according to a schedule established by the department.
49.688(7)(a)(a) Except as provided in
par. (b), from the appropriation accounts under
s. 20.435 (4) (bv),
(j), and
(pg), beginning on September 1, 2002, the department shall, under a schedule that is identical to that used by the department for payment of pharmacy provider claims under medical assistance, provide to pharmacies and pharmacists payments for prescription drugs sold by the pharmacies or pharmacists to persons eligible under
sub. (2) who have paid the deductible specified under
sub. (3) (b) 1. or
2. or who, under
sub. (3) (b) 1., are not required to pay a deductible. The payment for each prescription drug under this paragraph shall be at the program payment rate, minus any copayment paid by the person under
sub. (5) (a) 2. or
4., and plus, if applicable, incentive payments that are similar to those provided under
s. 49.45 (8v). The department shall devise and distribute a claim form for use by pharmacies and pharmacists under this paragraph and may limit payment under this paragraph to those prescription drugs for which payment claims are submitted by pharmacists or pharmacies directly to the department. The department may apply to the program under this section the same utilization and cost control procedures that apply under rules promulgated by the department to medical assistance under
subch. IV of ch. 49.
49.688(7)(b)
(b) During any period in which funding under
s. 20.435 (4) (bv) and
(pg) is completely expended for the payments specified in
par. (a), the requirements of
par. (a) and
subs. (3) (c),
(5), and
(6) (a) and
(b) do not apply to drugs purchased during that period, but the department shall continue to accept applications and determine eligibility under
sub. (4) and shall indicate to applicants that the eligibility of program participants to purchase prescription drugs as specified in
sub. (3), under the requirements of
sub. (5), is conditioned on the availability of funding under
s. 20.435 (4) (bv) and
(pg).
49.688(8)
(8) The department shall, under methods promulgated by the department by rule, monitor compliance by pharmacies and pharmacists that are certified providers of medical assistance with the requirements of
sub. (5) and shall annually report to the legislature under
s. 13.172 (2) concerning the compliance. The report shall include information on any pharmacies or pharmacists that discontinue participation as certified providers of medical assistance and the reasons given for the discontinuance.
49.688(8m)(b)
(b) An insurer that issues or delivers a disability insurance policy that provides coverage to a resident of this state shall provide to the department, upon the department's request, information contained in the insurer's records regarding all of the following:
49.688(8m)(b)1.
1. Information that the department needs to identify eligible persons under this section who satisfy any of the following:
49.688(8m)(b)1.b.
b. Would be eligible for benefits under a disability insurance policy if the eligible person were enrolled as a dependent of a person insured under the disability insurance policy.
49.688(8m)(b)2.
2. Information required for submittal of claims under the insurer's disability insurance policy.
49.688(8m)(b)3.
3. The types of benefits provided by the disability insurance policy.
49.688(8m)(c)
(c) Upon requesting an insurer to provide the information under
par. (b), the department shall enter into a written agreement with the insurer that satisfies all of the following:
49.688(8m)(c)2.
2. Includes provisions that adequately safeguard the confidentiality of the information to be disclosed.
49.688(8m)(d)1.1. An insurer shall provide the information requested under
par. (b) within 180 days after receiving the department's request if it is the first time that the department has requested the insurer to disclose information under this subsection.
49.688(8m)(d)2.
2. An insurer shall provide the information requested under
par. (b) within 30 days after receiving the department's request if the department has previously requested the insurer to disclose information under this subsection.
49.688(8m)(d)3.
3. If an insurer fails to comply with
subd. 1. or
2., the department may notify the commissioner of insurance, and the commissioner of insurance may initiate enforcement proceedings against the insurer under
s. 601.41 (4) (a).
49.688(9)(a)(a) The department shall promulgate rules relating to prohibitions on fraud that are substantially similar to applicable provisions under
s. 49.49 (1) (a).
49.688(9)(b)
(b) A person who is convicted of violating a rule promulgated by the department under
par. (a) in connection with that person's furnishing of prescription drugs under this section is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in
s. 939.50 (3) (h), the person may be fined not more than $25,000.
49.688(9)(c)
(c) A person other than a person specified in
par. (b) who is convicted of violating a rule promulgated by the department under
par. (a) may be fined not more than $10,000, or imprisoned in the county jail for not more than one year, or both.
