2023 - 2024 LEGISLATURE
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2023 SENATE BILL 100
March 1, 2023 - Introduced by Senators JACQUE, WANGGAARD, CARPENTER, JAMES,
CABRAL-GUEVARA, L. JOHNSON, LARSON, QUINN, ROYS and TAYLOR, cosponsored
by Representatives TITTL, ARMSTRONG, SUBECK, BEHNKE, KRUG, MURPHY,
MURSAU, ROZAR, SCHRAA, C. ANDERSON, J. ANDERSON, BALDEH, BARE, BROOKS,
CABRERA, DRAKE, GREEN, GUNDRUM, JACOBSON, JOERS, O'CONNOR, OHNSTAD,
RATCLIFF, RODRIGUEZ, SCHMIDT, SCHUTT, SHANKLAND, SINICKI, SPIROS, STUBBS
and WICHGERS. Referred to Committee on Insurance and Small Business.
1 AN ACT to amend 40.51 (8), 40.51 (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1)
2 (intro.) and 609.83; and to create 632.862 of the statutes; relating to:
3 application of prescription drug payments to health insurance cost-sharing
4 requirements.
Analysis by the Legislative Reference Bureau
Health insurance policies and plans often apply deductibles and out-of-pocket
maximum amounts to the benefits covered by the policy or plan. A deductible is an
amount that an enrollee in a policy or plan must pay out of pocket before attaining
the full benefits of the policy or plan. An out-of-pocket maximum amount is a limit
specified by a policy or plan on the amount that an enrollee pays, and, once that limit
is reached, the policy or plan covers the benefit entirely. This bill generally requires
health insurance policies that offer prescription drug benefits, self-insured health
plans, and pharmacy benefit managers acting on behalf of policies or plans to apply
amounts paid by or on behalf of an individual covered under the policy or plan for
brand name prescription drugs to any cost-sharing requirement or to any
calculation of an out-of-pocket maximum amount of the policy or plan. Health
insurance policies are referred to in the bill as disability insurance policies.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
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SENATE BILL 100 SECTION 1
1 SECTION 1. 40.51 (8) of the statutes is amended to read:
2 40.51 (8) Every health care coverage plan offered by the state under sub. (6)
3 shall comply with ss. 631.89, 631.90, 631.93 (2), 631.95, 632.72 (2), 632.729, 632.746
4 (1) to (8) and (10), 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853,
5 632.855, 632.861, 632.862, 632.867, 632.87 (3) to (6), 632.885, 632.89, 632.895 (5m)
6 and (8) to (17), and 632.896.
7 SECTION 2. 40.51 (8m) of the statutes is amended to read:
8 40.51 (8m) Every health care coverage plan offered by the group insurance
9 board under sub. (7) shall comply with ss. 631.95, 632.729, 632.746 (1) to (8) and (10),
10 632.747, 632.748, 632.798, 632.83, 632.835, 632.85, 632.853, 632.855, 632.861,
11 632.862, 632.867, 632.885, 632.89, and 632.895 (11) to (17).
12 SECTION 3. 66.0137 (4) of the statutes is amended to read:
13 66.0137 (4) SELF-INSURED HEALTH PLANS. If a city, including a 1st class city, or
14 a village provides health care benefits under its home rule power, or if a town
15 provides health care benefits, to its officers and employees on a self-insured basis,
16 the self-insured plan shall comply with ss. 49.493 (3) (d), 631.89, 631.90, 631.93 (2),
17 632.729, 632.746 (10) (a) 2. and (b) 2., 632.747 (3), 632.798, 632.85, 632.853, 632.855,
18 632.861, 632.862, 632.867, 632.87 (4) to (6), 632.885, 632.89, 632.895 (9) to (17),
19 632.896, and 767.513 (4).
20 SECTION 4. 120.13 (2) (g) of the statutes is amended to read:
21 120.13 (2) (g) Every self-insured plan under par. (b) shall comply with ss.
22 49.493 (3) (d), 631.89, 631.90, 631.93 (2), 632.729, 632.746 (10) (a) 2. and (b) 2.,
23 632.747 (3), 632.798, 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (4)
24 to (6), 632.885, 632.89, 632.895 (9) to (17), 632.896, and 767.513 (4).
25 SECTION 5. 185.983 (1) (intro.) of the statutes is amended to read:
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SENATE BILL 100 SECTION 5
1 185.983 (1) (intro.) Every voluntary nonprofit health care plan operated by a
2 cooperative association organized under s. 185.981 shall be exempt from chs. 600 to
3 646, with the exception of ss. 601.04, 601.13, 601.31, 601.41, 601.42, 601.43, 601.44,
4 601.45, 611.26, 611.67, 619.04, 623.11, 623.12, 628.34 (10), 631.17, 631.89, 631.93,
5 631.95, 632.72 (2), 632.729, 632.745 to 632.749, 632.775, 632.79, 632.795, 632.798,
6 632.85, 632.853, 632.855, 632.861, 632.862, 632.867, 632.87 (2) to (6), 632.885,
7 632.89, 632.895 (5) and (8) to (17), 632.896, and 632.897 (10) and chs. 609, 620, 630,
8 635, 645, and 646, but the sponsoring association shall:
9 SECTION 6. 609.83 of the statutes is amended to read:
10 609.83 Coverage of drugs and devices; application of payments.
11 Limited service health organizations, preferred provider plans, and defined network
12 plans are subject to ss. 632.853, 632.861, 632.862, and 632.895 (16t) and (16v).
13 SECTION 7. 632.862 of the statutes is created to read:
14 632.862 Application of prescription drug payments. (1) DEFINITIONS. In
15 this section:
16 (a) “Brand name” has the meaning given in s. 450.12 (1) (a).
17 (b) “Brand name drug” means any of the following:
18 1. A prescription drug that contains a brand name and that has no medically
19 appropriate generic equivalent.
20 2. A prescription drug that contains a brand name and that has a medically
21 appropriate generic equivalent but to which the enrollee or other covered individual
22 has obtained access through any of the following:
23 a. Prior authorization.
24 b. A step therapy protocol.
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SENATE BILL 100 SECTION 7
1 c. The exceptions and appeals process of the disability insurance policy,
2 self-insured health plan, or pharmacy benefit manager.
3 (c) “Cost-sharing requirement” means a deductible, copayment, or
4 coinsurance.
5 (d) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a).
6 (e) “Generic equivalent” means a drug product equivalent, as defined in s.
7 450.13 (1e), that is nationally available.
8 (f) “Pharmacy benefit manager” has the meaning given in s. 632.865 (1) (c).
9 (g) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
10 (2) APPLICATION OF PAYMENTS. Except as provided in sub. (4), a disability
11 insurance policy that offers a prescription drug benefit, a self-insured health plan,
12 or a pharmacy benefit manager acting on behalf of a disability insurance policy or
13 self-insured health plan shall apply to any cost-sharing requirement or to any
14 calculation of an out-of-pocket maximum amount of the disability insurance policy
15 or self-insured health plan, including the annual limitations on cost sharing
16 established under 42 USC 18022 (c) and 42 USC 300gg-6 (b), any amounts paid by
17 an enrollee or other individual covered under the disability insurance policy or
18 self-insured health plan, or by any person on behalf of the enrollee or individual, for
19 brand name drugs that are covered under the disability insurance policy or
20 self-insured health plan.
21 (3) CALCULATION OF COST-SHARING ANNUAL LIMITATIONS. For purposes of
22 calculating an enrollee's contribution to the annual limitation on cost sharing under
23 42 USC 18022 (c) and 42 USC 300gg-6 (b), a disability insurance policy that offers
24 a prescription drug benefit, a self-insured health plan, or a pharmacy benefit
25 manager acting on behalf of a disability insurance policy or self-insured health plan
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SENATE BILL 100 SECTION 7
1 shall include expenditures for any item or service covered under the disability
2 insurance policy or self-insured health plan if the item or service is included within
3 a category of essential health benefits, as described in 42 USC 18022 (b) (1), and
4 regardless of whether the disability insurance policy, self-insured health plan, or
5 pharmacy benefit manager classifies the item or service as an essential health
6 benefit.
7 (4) EXCEPTION; HIGH DEDUCTIBLE HEALTH PLANS. If applying the requirement
8 under sub. (2) to payments made by or on behalf of an enrollee or other individual
9 covered under a high deductible health plan, as defined under 26 USC 223 (c) (2),
10 would result in the enrollee failing to meet the definition of an eligible individual
11 under 26 USC 223 (c) (1), the disability insurance policy, self-insured health plan,
12 or pharmacy benefit manager shall begin applying the requirement under sub. (2)
13 to the disability insurance policy or self-insured health plan's deductible after the
14 enrollee has satisfied the minimum deductible requirement under 26 USC 223 (c) (2)
15 (A) (i). This subsection does not apply to any amounts paid for items or services that
16 are preventive care, as described in 26 USC 223 (c) (2) (C).
17 SECTION 8.0Initial applicability.
18 (1) (a) For policies and plans containing provisions inconsistent with this act,
19 the act first applies to policy or plan years beginning on January 1 of the year
20 following the year in which this paragraph takes effect, except as provided in par. (b).
21 (b) For policies or plans that are affected by a collective bargaining agreement
22 containing provisions inconsistent with this act, this act first applies to policy or plan
23 years beginning on the effective date of this paragraph or on the day on which the
24 collective bargaining agreement is newly established, extended, modified, or
25 renewed, whichever is later.
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SENATE BILL 100 SECTION 9
1 SECTION 9.0Effective date.
2 (1) This act takes effect on the first day of the 4th month beginning after
3 publication.
4 (END)


Statutes affected:
Bill Text: 40.51(8), 40.51, 40.51(8m), 66.0137(4), 66.0137, 120.13(2)(g), 120.13, 185.983(1)(intro.), 185.983, 609.83