632.861(4)(b) (b)

632.861(4)(b)1. 1. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if the prescription drug that is to be removed or reassigned is any of the following:

632.861(4)(b)1.a. a. No longer approved by the federal food and drug administration.

632.861(4)(b)1.b. b. The subject of a notice, guidance, warning, announcement, or other statement from the federal food and drug administration relating to concerns about the safety of the prescription drug.

632.861(4)(b)1.c. c. Approved by the federal food and drug administration for use without a prescription.

632.861(4)(b)2. 2. A disability insurance policy, self-insured health plan, or pharmacy benefit manager is not required to provide advanced written notice under par. (a) if, for the prescription drug that is being removed from the formulary or reassigned to a benefit tier that has a higher deductible, copayment, or coinsurance, the policy, plan, or pharmacy benefit manager adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:

632.861(4)(b)2.a. a. The same benefit tier from which the prescription drug is being removed or reassigned.

632.861(4)(b)2.b. b. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.

632.861(4)(c) (c) A pharmacist or pharmacy shall notify an enrollee in a disability insurance policy or self-insured health plan if a prescription drug for which an enrollee is filling or refilling a prescription is removed from the formulary and the policy or plan or a pharmacy benefit manager acting on behalf of a policy or plan adds to the formulary a generic prescription drug that is approved by the federal food and drug administration for use as an alternative to the prescription drug or a prescription drug in the same pharmacologic class or with the same mechanism of action at any of the following benefit tiers:

632.861(4)(c)1. 1. The same benefit tier from which the prescription drug is being removed or reassigned.

632.861(4)(c)2. 2. A benefit tier that has a lower deductible, copayment, or coinsurance than the benefit tier from which the prescription drug is being removed or reassigned.

632.861(4)(d) (d) If an enrollee has had an adverse reaction to the generic prescription drug or the prescription drug in the same pharmacologic class or with the same mechanism of action that is being substituted for an originally prescribed drug, the pharmacist or pharmacy may extend the prescription order for the originally prescribed drug to fill one 30-day supply of the originally prescribed drug for the cost-sharing amount that applies to the prescription drug at the time of the substitution.

632.861 History History: 2021 a. 9.

632.865 632.865 Pharmacy benefit managers.

632.865(1) (1) Definitions. In this section:

632.865(1)(ae) (ae) “Health benefit plan” has the meaning given in s. 632.745 (11).

632.865(1)(ak) (ak) “Health care provider” has the meaning given in s. 146.81 (1).

632.865(1)(aw) (aw) “Pharmacist” has the meaning given in s. 450.01 (15).

632.865(1)(b) (b) “Pharmacy” means an entity licensed under s. 450.06 or 450.065.

632.865(1)(c) (c) “Pharmacy benefit manager” means an entity doing business in this state that contracts to administer or manage prescription drug benefits on behalf of any of the following:

632.865(1)(c)1. 1. An insurer.

632.865(1)(c)2. 2. A cooperative, as defined in s. 185.01 (2).

632.865(1)(c)3. 3. Another entity that provides prescription drug benefits to residents of this state.

632.865(1)(d) (d) “Prescribed drug or device” has the meaning given in s. 450.01 (18).

632.865(1)(dm) (dm) “Prescription drug” has the meaning given in s. 450.01 (20).

632.865(1)(e) (e) “Prescription drug benefit” means coverage of or payment or assistance for prescribed drugs or devices.

632.865(2) (2) Pricing transparency.

632.865(2)(a) (a) The pharmacy benefit manager shall agree in each contract or renewal to do all of the following:

632.865(2)(a)1. 1. Update maximum allowable cost pricing information for prescribed drugs or devices at least every 7 business days and provide a means by which contracted pharmacies may promptly review pricing updates in a format that is readily available and accessible.