Chapter 102

102.423(2)(a)3. 3. The fee was paid within the applicable period under par. (c).

102.423(2)(b) (b)

102.423(2)(b)1. 1.

102.423(2)(b)1.a. a. If a notice from the department of health services under s. 50.38 (7m) (a) 1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38 (7m) (a) 1. a. or b. applies, then this section shall not apply from the day the notice is published until subd. 2. applies.

102.423(2)(b)1.b. b. Except as provided in subd. 1. a., if a notice from the department of health services under s. 50.38 (7m) (a) 1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38 (7m) (a) 1. c. or d. applies, then this section shall not apply beginning on the first day of the calendar year following the calendar year in which the notice is published until subd. 2. applies.

102.423(2)(b)2. 2.

102.423(2)(b)2.a. a. Notwithstanding subd. 1., if a notice from the department of health services under s. 50.38 (7m) (b) 1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38 (7m) (b) 1. a. or b. applies, then this section applies from the day the notice is published.

102.423(2)(b)2.b. b. Notwithstanding subd. 1. and except as provided in subd. 2. a., if a notice from the department of health services under s. 50.38 (7m) (b) 1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38 (7m) (b) 1. c. or d. applies, then this section applies beginning on the first day of the calendar year following the calendar year in which the notice is published.

102.423(2)(c) (c)

102.423(2)(c)1. 1. In order for this section to apply to a fee, an insurer or self-insured employer must remit payment for the fee to the eligible hospital within the period specified in subd. 2., which shall begin to run on the day after whichever of the following dates is latest:

102.423(2)(c)1.a. a. The date the eligible hospital electronically sends to the insurer or self-insured employer the medical records to substantiate the submitted hospital bill or, if such records are sent by mail, the 3rd day after the date the records are postmarked.

102.423(2)(c)1.b. b. The date the eligible hospital electronically sends the bill described in subd. 1. a. or, if the bill is sent by mail, the 3rd day after the date the bill is postmarked.

102.423(2)(c)2. 2.

102.423(2)(c)2.a. a. If the aggregate amount billed is equal to or greater than $65,000, the period within which an insurer or self-insured employer must remit payment shall be 90 calendar days after the date determined under subd. 1.

102.423(2)(c)2.b. b. If the aggregate amount billed is less than $65,000, the period within which an insurer or self-insured employer must remit payment shall be 60 calendar days after the date determined under subd. 1.

102.423(2)(c)3. 3. An insurer or self-insured employer may request that an eligible hospital send additional medical records to the insurer or self-insured employer that the insurer or self-insured employer reasonably believes are necessary to substantiate the claim. The eligible hospital shall provide the requested records to the extent practicable or within 10 days after the request is received, but a request under this subdivision by an insurer or self-insured employer shall not operate to extend the period specified under subd. 2. a. or b.

102.423(2)(c)4. 4.

102.423(2)(c)4.a. a. An insurer or self-insured employer may submit a request to the department for an extension to the period specified in subd. 2. if the insurer or self-insured employer has not yet determined whether an injury is compensable under this chapter. The department may, pursuant to rules promulgated under subd. 4. e., authorize such an extension if the department determines that the insurer or self-insured employer has not yet determined compensability despite its good faith effort to do so. A single extension granted by the department shall not exceed 30 calendar days. There is no limit to the number of extensions that an insurer or self-insured employer may request or that the department may grant under this subdivision, but an insurer or self-insured employer may not request another extension after a denial.

102.423(2)(c)4.b. b. If the department denies a request for extension under this subdivision, the insurer or self-insured employer shall, notwithstanding subds. 1. and 2., have 14 calendar days after the denial to remit payment for the fee to the eligible hospital. If the insurer or self-insured employer remits payment for the fee to the eligible hospital within that 14-day period, then this section applies to that fee.

102.423(2)(c)4.c. c. A request by an insurer or self-insured employer for an extension under this subdivision or a denial by the department of a request for extension under this subdivision shall not be used as evidence of bad faith by the insurer or self-insured employer.

102.423(2)(c)4.d. d. Any information provided by an insurer or self-insured employer pursuant to this subdivision shall not be used as evidence of bad faith by the insurer or self-insured employer.

102.423(2)(c)4.e. e. The department shall promulgate rules specifying requirements and procedures for requesting and granting extensions under this subdivision. The rules shall specify requirements or procedures to ensure that notice is provided to an eligible hospital when a request is made under this subdivision.

102.423(3) (3) Establishment of schedule.

102.423(3)(a) (a) By July 1, 2027, the department shall establish a schedule of the maximum fees that the eligible hospital may charge an insurer or self-insured employer for an item or service provided to an injured employee who claims benefits under this chapter. When the schedule under this subsection is established, the department shall send a notice to the legislative reference bureau for publication in the Wisconsin Administrative Register of the date that the schedule will be effective, which shall be no earlier than the date the notice is published. In determining the maximum fees, the department shall divide the state into 5 regions based on geographical and economic similarity, including similarity in the cost of items and services, and, for each region, shall do all of the following:

102.423(3)(a)1. 1.

102.423(3)(a)1.a. a. Determine, for each item or service included in the schedule, the amount that represents the 75th percentile of the commercial, in-network negotiated amounts, across all commercial health insurance plans, issuers, and administrators in that region. The department shall make the determinations under this subd. 1. a. in accordance with subd. 1. b. and c.

102.423(3)(a)1.b. b. In order to determine the amounts under this subdivision, the department shall utilize the machine-readable files of all health insurance plans, issuers, administrators, and hospitals made public pursuant to 26 CFR 54.9815-2715A3, 29 CFR 2590.715-2715A3, 45 CFR 147.212, and 45 CFR 180.40 (a) that contain in-network negotiated rates for each eligible hospital in that region.

102.423(3)(a)1.c. c. In determining the amounts under this subdivision, the department shall not use any amounts from Medicare advantage, services provided under a managed care system under the Medical Assistance program under subch. IV of ch. 49, databases certified by the department under s. 102.16 (2) (h), or any sources other than those specified in subd. 1. b.

102.423(3)(a)2. 2. Set the maximum fee for each item or service included in the schedule at 120 percent of the amount determined under subd. 1. for that region.

102.423(3)(am) (am) The department shall contract with a 3rd party to perform the duties specified under pars. (a) 1. and 2.

102.423(3)(b) (b) Every year, the department shall redetermine the schedule of maximum fees using the procedures specified in par. (a), subject to par. (am).

102.423(3)(d) (d) The department shall publish the current fee schedule established under this subsection on the department’s website. Notwithstanding s. 227.10 (1), the fee schedule need not be promulgated as a rule.

102.423(4) (4) Liability of insurer or self-insured employer.

102.423(4)(a) (a) The liability of an insurer or self-insured employer for an item or service included in a fee schedule established under sub. (3) is limited to the maximum fee allowed under the schedule for the item or service as of the date on which the item or service was provided, any fee agreed to by contract between the insurer or self-insured employer and eligible hospital for the item or service as of that date, or the eligible hospital’s actual fee for the item or service as of that date, whichever is least.

102.423(4)(b) (b) An eligible hospital that provides items or services to an injured employee under this chapter may not collect, or bring an action to collect, from the injured employee any charge that is in excess of the liability of the insurer or self-insured employer under this subsection.

102.423(4)(c) (c) A schedule of maximum fees established under sub. (3) first applies to an item or service provided to an injured employee on the effective date specified in the notice published under sub. (3) (a).

102.423(4)(d) (d) Payment of a claim pursuant to this section is not an admission of causality or responsibility with respect to any future payments or obligations.

102.423(5) (5) Rules. The department shall, subject to sub. (3) (d), promulgate rules to implement this section.

102.423 History History: 2025 a. 15.

102.425 102.425 Prescription and nonprescription drug treatment.

102.425(1) (1) Definitions. In this section:

102.425(1)(a) (a) “Dispense” has the meaning given in s. 450.01 (7).

102.425(1)(b) (b) “Drug” has the meaning given in s. 450.01 (10).

102.425(1)(c) (c) “Drug product equivalent” has the meaning given in s. 450.13 (1e).

102.425(1)(cm) (cm) “Licensed pharmacy” means a pharmacy licensed under s. 450.06 or 450.065.

102.425(1)(d) (d) “Nonprescription drug product” has the meaning given in s. 450.01 (13m).

102.425(1)(e) (e) “Pharmacist” has the meaning given in s. 450.01 (15).

102.425(1)(f) (f) “Practitioner” has the meaning given in s. 450.01 (17).

102.425(1)(g) (g) “Prescription” has the meaning given in s. 450.01 (19).

102.425(1)(h) (h) “Prescription drug” has the meaning given in s. 450.01 (20).

102.425(1)(i) (i) “Prescription order” has the meaning given in s. 450.01 (21).

102.425(2) (2) Substitution of drug product equivalents.

102.425(2)(a) (a) Except as provided in pars. (b) and (c), when a drug is prescribed to treat an injury for which an employer or insurer is liable under this chapter, the pharmacist or practitioner dispensing the drug shall substitute a drug product equivalent in place of the prescribed drug if all of the following apply:

102.425(2)(a)1. 1. In the professional judgment of the dispensing pharmacist or practitioner, the drug product equivalent is therapeutically equivalent to the prescribed drug.

102.425(2)(a)2. 2. The charge for the drug product equivalent is less than the charge for the prescribed drug.

102.425(2)(b) (b) A pharmacist or practitioner may not substitute a drug product equivalent under par. (a) in place of a prescribed drug if any of the following apply:

102.425(2)(b)1. 1. The prescribed drug is a single-source patented drug for which there is no drug product equivalent.

102.425(2)(b)2. 2. The prescriber determines that the prescribed drug is medically necessary and indicates that no substitution may be made for that prescribed drug by writing on the face of the prescription order or, in the case of a prescription order that is transmitted electronically, by designating in electronic format the phrase “No substitutions” or “Dispense as written” or words of similar meaning or the initials “N.S.” or “D.A.W.”

102.425(2)(c) (c) Unless par. (b) applies, if an injured employee requests that a specific brand name drug be used to treat the employee’s injury, the pharmacist or practitioner dispensing the prescription shall dispense the specific brand name drug as requested. If a specific brand name drug is dispensed under this paragraph, the employer or insurer and the employee shall share the cost of the prescription as follows:

102.425(2)(c)1. 1. The employer or insurer shall be liable in an amount equal to the average wholesale price, as determined under sub. (3) (a) 1., of the lowest-priced drug product equivalent that the pharmacist or practitioner has in stock on the day on which the brand name drug is dispensed, plus the dispensing fee under sub. (3) (a) 2. and any applicable taxes under sub. (3) (a) 3. that would be payable for that drug product equivalent.

102.425(2)(c)2. 2. The employee shall be liable in an amount equal to the difference between the amount for which the employer or insurer is liable under subd. 1. and an amount equal to the average wholesale price, as determined under sub. (3) (a) 1., of the brand name drug on the day on which the brand name drug is dispensed, plus any applicable taxes under sub. (3) (a) 3. that are payable for that brand name drug.

102.425(3) (3) Liability of employer or insurer.

102.425(3)(a) (a) The liability of an employer or insurer for the cost of a prescription drug dispensed under sub. (2) for outpatient use by an injured employee, including a prescription drug dispensed outside of a licensed pharmacy, is limited to the sum of all of the following:

102.425(3)(a)1. 1. The average wholesale price of the prescription drug as of the date on which the prescription drug is dispensed, as quoted in the Drug Topics Red Book, published by Medical Economics Company, Inc., or its successor, or, if that book is discontinued and becomes unavailable, as quoted in another nationally recognized pricing source determined by the department.

102.425(3)(a)2. 2. A dispensing fee of $3 per prescription order, which shall be payable for all prescription drugs dispensed under sub. (2) regardless of the location from which the prescription drug is dispensed, but which shall be payable only to a pharmacist who dispenses the prescription drug.

102.425(3)(a)3. 3. Any state or federal taxes that may be applicable to the prescription drug dispensed.

102.425(3)(b) (b) In addition to the liability under par. (a), an employer or insurer is also liable for reimbursement to an injured employee for all out-of-pocket expenses incurred by the injured employee in obtaining the prescription drug dispensed.

102.425(3)(c) (c) A billing statement submitted to an employer or insurer for a prescription drug dispensed under sub. (2) shall include the national drug code number of the prescription as listed in the national drug code directory maintained by the federal food and drug administration and shall state separately the price of the prescription drug and the dispensing fee.

102.425(4) (4) Liability of employee.

102.425(4)(a) (a) Except as provided in par. (b), a pharmacist or practitioner who dispenses a prescription drug under sub. (2) to an injured employee may not collect, or bring an action to collect, from the injured employee any charge that is in excess of the liability of the injured employee under sub. (2) (c) 2. or the liability of the employer or insurer under sub. (3) (a).

102.425(4)(b) (b) If an employer or insurer denies or disputes liability for the cost of a drug prescribed to an injured employee under sub. (2), the pharmacist or practitioner who dispensed the drug may collect, or bring an action to collect, from the injured employee the cost of the prescription drug dispensed, subject to the limitations specified in sub. (3) (a). If an employer or insurer concedes liability for the cost of a drug prescribed to an injured employee under sub. (2), but disputes the reasonableness of the amount charged for the prescription drug, the employer or insurer shall provide notice under sub. (4m) (b) to the pharmacist or practitioner that the reasonableness of the amount charged is in dispute and the pharmacist or practitioner who dispensed the drug may not collect, or bring an action to collect, from the injured employee the cost of the prescription drug dispensed after receiving that notice.

102.425(4m) (4m) Resolution of prescription drug charge disputes.

102.425(4m)(a) (a) The department has jurisdiction under this subsection and ss. 102.16 (1m) (c) and 102.17 to resolve a dispute between a pharmacist or practitioner and an employer or insurer over the reasonableness of the amount charged for a prescription drug dispensed under sub. (2) for outpatient use by an injured employee who claims benefits under this chapter.

102.425(4m)(b) (b) An employer or insurer that disputes the reasonableness of the amount charged for a prescription drug dispensed under sub. (2) for outpatient use by an injured employee or the department under sub. (4) (b) or s. 102.16 (1m) (c) or 102.18 (1) (bg) 3. shall provide, within 30 days after receiving a completed bill for the prescription drug, reasonable written notice to the pharmacist or practitioner that the charge is being disputed. After receiving reasonable written notice under this paragraph or under sub. (4) (b) or s. 102.16 (1m) (c) or 102.18 (1) (bg) 3. that a prescription drug charge is being disputed, a pharmacist or practitioner may not collect the disputed charge from, or bring an action for collection of the disputed charge against, the employee who received the prescription drug.

102.425(4m)(c) (c) A pharmacist or practitioner that receives notice under par. (b) that the reasonableness of the amount charged for a prescription drug dispensed under sub. (2) for outpatient use by an injured employee is in dispute shall file the dispute with the department within 6 months after receiving that notice.

102.425(4m)(d) (d) The department shall deny payment of a prescription drug charge that the department determines under this subsection to be unreasonable. A pharmacist or practitioner and an employer or insurer that are parties to a dispute under this subsection over the reasonableness of a prescription drug charge are bound by the department’s determination under this subsection on the reasonableness of the disputed charge, unless that determination is set aside on judicial review as provided in par. (e).

102.425(4m)(e) (e) Within 30 days after a determination under this subsection, the department may set aside, reverse, or modify the determination for any reason that the department considers sufficient. Within 60 days after a determination under this subsection, the department may set aside, reverse, or modify the determination on grounds of mistake. A pharmacist, practitioner, employer, or insurer that is aggrieved by a determination of the department under this subsection may seek judicial review of that determination in the same manner that compensation claims are reviewed under s. 102.23.

102.425(5) (5) Nonprescription drug products. The liability of an employer or insurer for the cost of a nonprescription drug product used to treat an injured employee is limited to the usual and customary charge to the general public for the nonprescription drug product.

102.425 History History: 2005 a. 172; 2007 a. 185; 2009 a. 206; 2015 a. 55, 180; 2017 a. 149; 2025 a. 33.

102.43 102.43 Weekly compensation schedule. If the injury causes disability, an indemnity shall be due as wages commencing the 4th calendar day from the commencement of the day the scheduled work shift began, exclusive of Sundays only, excepting where the employee works on Sunday, after the employee leaves work as the result of the injury, and shall be payable weekly thereafter, during such disability. If the disability exists after 7 calendar days from the date the employee leaves work as a result of the injury and only if it so exists, indemnity shall also be due and payable for the first 3 calendar days, exclusive of Sundays only, excepting where the employee works on Sunday. Said weekly indemnity shall be as follows:

102.43(1) (1) If the injury causes total disability, two-thirds of the average weekly earnings during such disability.

102.43(2) (2) If the injury causes partial disability, during the partial disability, such proportion of the weekly indemnity rate for total disability as the actual wage loss of the injured employee bears to the injured employee’s average weekly wage at the time of the injury.

102.43(3) (3) If the disability caused by the injury is at times total and at times partial, the weekly indemnity during each total or partial disability shall be in accordance with subs. (1) and (2), respectively.

102.43(4) (4) If the disability period involves a fractional week, indemnity shall be paid for each day of such week, except Sundays only, at the rate of one-sixth of the weekly indemnity.

102.43(5) (5) 

102.43(5)(a) (a) Temporary disability, during which compensation shall be payable for loss of earnings, shall include such period as may be reasonably required for training in the use of artificial members and appliances.

102.43(5)(b) (b) Except as provided in s. 102.61 (1g), temporary disability shall also include such period as the employee may be receiving instruction under s. 102.61 (1) or (1m). Temporary disability on account of receiving instruction under s. 102.61 (1) or (1m), and not otherwise resulting from the injury, shall not be in excess of 80 weeks. That 80-week limitation does not apply to temporary disability benefits under this section, the cost of tuition, fees, books, travel, or maintenance under s. 102.61 (1), or the cost of private rehabilitation counseling or rehabilitative training under s. 102.61 (1m) if the department determines that additional training is warranted. The necessity for additional training as authorized by the department for any employee shall be subject to periodic review and reevaluation.

102.43(5)(c) (c) Compensation for temporary disability on account of receiving instruction under s. 102.61 (1) or (1m) shall not be reduced under sub. (2) on account of any wages earned for the first 24 hours worked by an employee during a week in which the employee is receiving that instruction. If an employee performs more than 24 hours of work during a week in which the employee is receiving that instruction, all wages earned for hours worked in excess of 24 during that week shall be offset against the employee’s average weekly wage in calculating compensation for temporary disability under sub. (2). An employee who is receiving compensation for temporary disability on account of receiving instruction under s. 102.61 (1) or (1m) shall report any wages earned during the period in which the employee is receiving that instruction to the insurance carrier or self-insured employer paying that compensation.

102.43(6) (6)