49.687 Disease aids; patient requirements; rebate agreements; cost containment.

(1) The department shall promulgate rules that require a person who is eligible for benefits under s. 49.68, 49.683, or 49.685 and whose estimated total family income for the current year is at or above 200 percent of the poverty line to obligate or expend specified portions of the income for medical care for treatment of kidney disease, cystic fibrosis, or hemophilia before receiving benefits under s. 49.68, 49.683, or 49.685. The rules shall require a person to pay 0.50 percent of his or her total family income for the cost of medical treatment covered under s. 49.68, 49.683, or 49.685 if that income is from 200 percent to 250 percent of the federal poverty line, 0.75 percent if that income is more than 250 percent but not more than 275 percent of the federal poverty line, 1 percent if that income is more than 275 percent but not more than 300 percent of the federal poverty line, 1.25 percent if that income is more than 300 percent but not more than 325 percent of the federal poverty line, 2 percent if that income is more than 325 percent but not more than 350 percent of the federal poverty line, 2.75 percent if that income is more than 350 percent but not more than 375 percent of the federal poverty line, 3.5 percent if that income is more than 375 percent but not more than 400 percent of the federal poverty line, and 4.5 percent if that income is more than 400 percent of the federal poverty line.

(1m)

(a) A person is not eligible to receive benefits under s. 49.68 or 49.683 unless before the person applies for benefits under s. 49.68 or 49.683, the person first applies for benefits under all other health care coverage programs specified by the department by rule for which the person reasonably may be eligible.

(b) The department shall promulgate rules that specify other health care coverage programs for which a person must apply before applying for benefits under s. 49.685. The department may waive the requirement under this paragraph for an applicant who requests a waiver for religious reasons.

(c) Using the procedure under s. 227.24, the department may promulgate rules under par. (b) for the period before the effective date of any permanent rules promulgated under par. (b), but not to exceed the period authorized under s. 227.24 (1) (c) and (2). Notwithstanding s. 227.24 (1) (a), (2) (b), and (3), the department is not required to provide evidence that promulgating a rule under par. (b) as an emergency rule is necessary for the preservation of the public peace, health, safety, or welfare and is not required to make a finding of emergency for promulgating a rule under par. (b) as an emergency rule.

(2) The department shall develop and implement a sliding scale of patient liability for kidney disease aid under s. 49.68, cystic fibrosis aid under s. 49.683, and hemophilia treatment under s. 49.685, based on the patient's ability to pay for treatment. The department shall continuously review the sliding scale for patient liability and revise it as needed to ensure that the amounts budgeted under s. 20.435 (4) (e) and (je) are sufficient to cover treatment costs.

(2m) If a pharmacy directly bills the department or an entity with which the department contracts for a drug supplied to a person receiving benefits under s. 49.68, 49.683, or 49.685 and prescribed for treatment covered under s. 49.68, 49.683, or 49.685, the person shall pay a $7.50 copayment amount for each such generic drug and a $15 copayment amount for each such brand name drug.

(3) The department or an entity with which the department contracts shall provide to a drug manufacturer that sells drugs for prescribed use in this state documents designed for use by the manufacturer in entering into a rebate agreement with the department or entity that is modeled on the rebate agreement specified under 42 USC 1396r-8. The department or entity may enter into a rebate agreement under this subsection that shall include all of the following as requirements:

(a) That, as a condition of coverage for prescription drugs of a manufacturer under s. 49.68, 49.683, or 49.685, the manufacturer shall make rebate payments for each prescription drug of the manufacturer that is prescribed for and purchased by persons who meet eligibility criteria under s. 49.68, 49.683, or 49.685, to the secretary of administration to be credited to the appropriation under s. 20.435 (4) (je), each calendar quarter or according to a schedule established by the department.

(b) That the amount of the rebate payment shall be determined by a method specified in 42 USC 1396r-8 (c).

(4) The department may adopt managed care methods of cost containment for the programs under ss. 49.68, 49.683, and 49.685.

(6) The department shall obtain and share information about individuals who receive benefits under s. 49.68, 49.683, or 49.685 as provided in s. 49.475.

History: 1983 a. 27; 1989 a. 56; 1991 a. 39; 1993 a. 16, 449; 1995 a. 27 ss. 3063 to 3065; Stats. 1995 s. 49.687; 1997 a. 27; 1999 a. 9; 2001 a. 16; 2003 a. 33, 198; 2007 a. 20.