Bill Text: IL SB2790 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not enter into a contract with a managed care organization that relies on a pharmacy benefit manager that does not do the following: (i) utilize a pharmacy reimbursement methodology of the lesser of national average drug acquisition cost plus a professional dispensing fee as determined by the Department, the wholesale acquisition cost plus a professional dispensing fee as determined by the Department, or the usual and customary charge by the pharmacy; (ii) reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; (iii) agree to move to a transparent pass-through pricing model, in which the pharmacy benefit manager discloses the administrative fee as a percentage of the professional dispensing costs to the Department; (iv) agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and (v) agree to not terminate an existing contract with a pharmacy licensed under the Pharmacy Practice Act for the sole reason of the additional professional dispensing fee authorized under item (i). Requires each pharmacy benefit manager that receives reimbursement for medical services, either directly or through a Medicaid managed care health plan, to submit by January 15, 2026, and each January 15 thereafter, certain data and information to the Department for the previous fiscal year, including: (1) the total number of prescriptions that were dispensed; (2) the aggregate wholesale acquisition cost for each drug on its formulary; (3) the aggregate amount of rebates, discounts, and price concessions that the pharmacy benefit manager received for each drug on its formulary; (4) the aggregate amount of administrative fees that the pharmacy benefit manager received from all pharmaceutical manufacturers; and (5) any other information considered necessary by the Department. Requires the Department to submit such data and information to the General Assembly and to the Governor's Office of Management and Budget. Provides that such information is confidential and not subject to disclosure under the Freedom of Information Act.

Spectrum: Slight Partisan Bill (Democrat 5-3)

Status: (Introduced) 2024-05-02 - Added as Co-Sponsor Sen. Dale Fowler [SB2790 Detail]

Download: Illinois-2023-SB2790-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB2790 Introduced 1/17/2024, by Sen. Laura M. Murphy SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-36a new
Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not enter into a contract with a managed care organization that relies on a pharmacy benefit manager that does not do the following: (i) utilize a pharmacy reimbursement methodology of the lesser of national average drug acquisition cost plus a professional dispensing fee as determined by the Department, the wholesale acquisition cost plus a professional dispensing fee as determined by the Department, or the usual and customary charge by the pharmacy; (ii) reimburse for a legally valid claim at a rate not less than the rate in effect at the time the original claim adjudication was submitted at the point of sale; (iii) agree to move to a transparent pass-through pricing model, in which the pharmacy benefit manager discloses the administrative fee as a percentage of the professional dispensing costs to the Department; (iv) agree to not create new pharmacy administration fees and to not increase current fees more than the rate of inflation; and (v) agree to not terminate an existing contract with a pharmacy licensed under the Pharmacy Practice Act for the sole reason of the additional professional dispensing fee authorized under item (i). Requires each pharmacy benefit manager that receives reimbursement for medical services, either directly or through a Medicaid managed care health plan, to submit by January 15, 2026, and each January 15 thereafter, certain data and information to the Department for the previous fiscal year, including: (1) the total number of prescriptions that were dispensed; (2) the aggregate wholesale acquisition cost for each drug on its formulary; (3) the aggregate amount of rebates, discounts, and price concessions that the pharmacy benefit manager received for each drug on its formulary; (4) the aggregate amount of administrative fees that the pharmacy benefit manager received from all pharmaceutical manufacturers; and (5) any other information considered necessary by the Department. Requires the Department to submit such data and information to the General Assembly and to the Governor's Office of Management and Budget. Provides that such information is confidential and not subject to disclosure under the Freedom of Information Act.
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A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
adding Section 5-36a as follows:
(305 ILCS 5/5-36a new)
Sec. 5-36a. Managed care organizations; pharmacy benefit
managers; contract requirements.
(a) Notwithstanding any law or rule to the contrary, the
Department shall not enter into a contract with a managed care
organization that relies on a pharmacy benefit manager that
does not do all of the following:
(1) For pharmacies licensed under the Pharmacy
Practice Act, including offsite institutional pharmacies
as defined in Section 39.5 of the Pharmacy Practice Act,
utilize a pharmacy reimbursement methodology of the lesser
of national average drug acquisition cost plus a
professional dispensing fee as determined by the
Department, the wholesale acquisition cost plus a
professional dispensing fee as determined by the
Department, or the usual and customary charge by the
pharmacy. The pharmacy benefit manager or the involved
pharmacy services administrative organization, as defined

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in Section 5-36 of this Code, shall not receive any
portion of the professional dispensing fee. The Department
shall identify the pharmacies this subsection applies to
and provide the list of applicable pharmacies to managed
care organizations contracted with the Department.
(2) Reimburse for a legally valid claim at a rate not
less than the rate in effect at the time the original claim
adjudication was submitted at the point of sale.
(3) Agree to move to a transparent pass-through
pricing model, in which the pharmacy benefit manager
discloses the administrative fee as a percentage of the
professional dispensing costs to the Department.
(4) Agree to not create new pharmacy administration
fees and to not increase current fees more than the rate of
inflation. This paragraph does not apply to any federal
rule or action that creates a new fee.
(5) Agree to not terminate an existing contract with a
pharmacy licensed under the Pharmacy Practice Act for the
sole reason of the additional professional dispensing fee
authorized under this Section.
(b) Nothing in this Section shall be construed to prohibit
a managed care organization from implementing the provisions
of subsection (a) before the effective date of this amendatory
Act of the 103rd General Assembly.
(c) By January 15, 2026, and each January 15 thereafter,
each pharmacy benefit manager that receives reimbursement,

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either directly or through a Medicaid managed care health
plan, for medical services must submit all of the following
information to the Department for the previous fiscal year:
(1) The total number of prescriptions that were
dispensed.
(2) The aggregate wholesale acquisition cost for each
drug on its formulary.
(3) The aggregate amount of rebates, discounts, and
price concessions that the pharmacy benefit manager
received for each drug on its formulary. The amount of
rebates shall include any utilization discounts the
pharmacy benefit manager receives from a manufacturer.
(4) The aggregate amount of administrative fees that
the pharmacy benefit manager received from all
pharmaceutical manufacturers.
(5) The aggregate amount identified in paragraphs (2)
and (3) that was retained by the pharmacy benefit manager
and did not pass through to the Department or to the
Medicaid managed care health plan.
(6) The aggregate amount of reimbursements the
pharmacy benefit manager pays to contracting pharmacies.
(7) Any other information considered necessary by the
Department.
(d) By March 1, 2026 and each March 1 thereafter, the
Department shall submit the information provided under
subsection (c) to the General Assembly and the Governor's

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