SB 719

Elimination of cost sharing for prescription drugs under the Medical

Assistance program

Under current law, certain persons who receive health services under the

Medical Assistance program, also known in this state as BadgerCare, are required

to contribute a cost-sharing payment to the cost of certain health services. This bill

eliminates all cost-sharing payments for prescription drugs under the Medical

Assistance program. The Medical Assistance program is a joint state and federal

program that provides health services to individuals who have limited financial

resources.

Cost-sharing cap on insulin

This bill prohibits every health insurance policy and governmental

self-insured health plan that cover insulin and impose cost sharing on prescription

drugs from imposing cost sharing on insulin in an amount that exceeds $35 for a

one-month supply. Current law requires every health insurance policy that provides

coverage of expenses incurred for treatment of diabetes to provide coverage for

specified expenses and items, including insulin. The required coverage under

current law for certain diabetes treatments other than insulin infusion pumps is

subject to the same exclusions, limitations, deductibles, and coinsurance provisions

of the policy as other covered expenses. The bill's cost-sharing limitation on insulin

supersedes the specification that the exclusions, limitations, deductibles, and

coinsurance are the same as for other coverage.

Fiduciary and disclosure requirements for pharmacy benefit managers

The bill imposes fiduciary and disclosure requirements on pharmacy benefit

managers. Pharmacy benefit managers contract with health plans that provide

prescription drug benefits to administer those benefits for the plans. They also have

contracts with pharmacies and pay the pharmacies for providing the drugs to the

plan beneficiaries.

The bill provides that a pharmacy benefit manager owes a fiduciary duty to a

plan sponsor. The bill also requires that a pharmacy benefit manager annually

disclose all of the following information to the plan sponsor:

1. The indirect profit received by the pharmacy benefit manager from owning

a pharmacy or service provider.

2. Any payments made to a consultant or broker who works on behalf of the plan

sponsor.

3. From the amounts received from drug manufacturers, the amounts retained

by the pharmacy benefit manager that are related to the plan sponsor's claims or

bona fide service fees.

4. The amounts received from network pharmacies and the amount retained

by the pharmacy benefit manager.

Reimbursements for certain 340B program entities