2017 Wisconsin Statutes & Annotations
Chapter 632. Insurance contracts in specific lines.
632.865 Pharmacy benefit managers.
632.865 Pharmacy benefit managers.
(1) Definitions. In this section:
(a) “Pharmacist" has the meaning given in s. 450.01 (15).
(b) “Pharmacy" means an entity licensed under s. 450.06 or 450.065.
(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 insurer or other entity that provides prescription drug benefits to residents of this state.
(d) “Prescribed drug or device" has the meaning given in s. 450.01 (18).
(e) “Prescription drug benefit" means coverage of or payment or assistance for prescribed drugs or devices.
(2) Pricing transparency.
(a) The pharmacy benefit manager shall agree in each contract or renewal to do all of the following:
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.
2. Reimburse pharmacists and pharmacies for prescribed drugs or devices subject to maximum allowable cost information that has been updated at least every 7 business days.
3. Eliminate prescribed drugs or devices from the maximum allowable cost information or modify maximum allowable cost in a timely fashion consistent with availability of prescribed drugs or devices and pricing changes in the marketplace.
(b) A pharmacy benefit manger shall include in each contract with a pharmacy a process to appeal, investigate, and resolve disputes regarding maximum allowable cost pricing that includes all of the following:
1. A 21-day limit on the right to appeal following the initial claim.
2. A requirement that the appeal be investigated and resolved within 21 days after the date of the appeal.
3. A dedicated telephone number at which the pharmacy may contact the pharmacy benefit manager to speak to a person responsible for processing appeals.
4. A requirement that a pharmacy benefit manager provide a reason for any appeal denial and the national drug code published in a directory by the federal food and drug administration of a prescribed drug or device that may be purchased by retail network pharmacies at a price at or below the maximum allowable cost.
5. A requirement that a pharmacy benefit manager make a pricing adjustment no later than one day after the date of the final determination of the appeal.
