Bill Amendment: IL HB3631 | 2023-2024 | 103rd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: INS-PBM/INFORMATION DISCLOSURE
Status: 2023-08-04 - Public Act . . . . . . . . . 103-0453 [HB3631 Detail]
Download: Illinois-2023-HB3631-House_Amendment_001.html
Bill Title: INS-PBM/INFORMATION DISCLOSURE
Status: 2023-08-04 - Public Act . . . . . . . . . 103-0453 [HB3631 Detail]
Download: Illinois-2023-HB3631-House_Amendment_001.html
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1 | AMENDMENT TO HOUSE BILL 3631
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2 | AMENDMENT NO. ______. Amend House Bill 3631 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Insurance Code is amended by | ||||||
5 | changing Section 513b1 as follows:
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6 | (215 ILCS 5/513b1) | ||||||
7 | Sec. 513b1. Pharmacy benefit manager contracts. | ||||||
8 | (a) As used in this Section: | ||||||
9 | "340B drug discount program" means the program established
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10 | under Section 340B of the federal Public Health Service Act, | ||||||
11 | 42 U.S.C. 256b. | ||||||
12 | "340B entity" means a covered entity as defined in 42 | ||||||
13 | U.S.C. 256b(a)(4) authorized to participate in the 340B drug | ||||||
14 | discount program. | ||||||
15 | "340B pharmacy" means any pharmacy used to dispense 340B | ||||||
16 | drugs for a covered entity, whether entity-owned or external. |
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1 | "Biological product" has the meaning ascribed to that term | ||||||
2 | in Section 19.5 of the Pharmacy Practice Act. | ||||||
3 | "Maximum allowable cost" means the maximum amount that a | ||||||
4 | pharmacy benefit manager will reimburse a pharmacy for the | ||||||
5 | cost of a drug. | ||||||
6 | "Maximum allowable cost list" means a list of drugs for | ||||||
7 | which a maximum allowable cost has been established by a | ||||||
8 | pharmacy benefit manager. | ||||||
9 | "Pharmacy benefit manager" means a person, business, or | ||||||
10 | entity, including a wholly or partially owned or controlled | ||||||
11 | subsidiary of a pharmacy benefit manager, that provides claims | ||||||
12 | processing services or other prescription drug or device | ||||||
13 | services, or both, for health benefit plans. | ||||||
14 | "Retail price" means the price an individual without | ||||||
15 | prescription drug coverage would pay at a retail pharmacy, not | ||||||
16 | including a pharmacist dispensing fee. | ||||||
17 | "Third-party payer" means any entity that pays for | ||||||
18 | prescription drugs on behalf of a patient other than a health | ||||||
19 | care provider or sponsor of a plan subject to regulation under | ||||||
20 | Medicare Part D, 42 U.S.C. 1395w-101 , et seq. | ||||||
21 | (b) A contract between a health insurer and a pharmacy | ||||||
22 | benefit manager must require that the pharmacy benefit | ||||||
23 | manager: | ||||||
24 | (1) Update maximum allowable cost pricing information | ||||||
25 | at least every 7 calendar days. | ||||||
26 | (2) Maintain a process that will, in a timely manner, |
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1 | eliminate drugs from maximum allowable cost lists or | ||||||
2 | modify drug prices to remain consistent with changes in | ||||||
3 | pricing data used in formulating maximum allowable cost | ||||||
4 | prices and product availability. | ||||||
5 | (3) Provide access to its maximum allowable cost list | ||||||
6 | to each pharmacy or pharmacy services administrative | ||||||
7 | organization subject to the maximum allowable cost list. | ||||||
8 | Access may include a real-time pharmacy website portal to | ||||||
9 | be able to view the maximum allowable cost list. As used in | ||||||
10 | this Section, "pharmacy services administrative | ||||||
11 | organization" means an entity operating within the State | ||||||
12 | that contracts with independent pharmacies to conduct | ||||||
13 | business on their behalf with third-party payers. A | ||||||
14 | pharmacy services administrative organization may provide | ||||||
15 | administrative services to pharmacies and negotiate and | ||||||
16 | enter into contracts with third-party payers or pharmacy | ||||||
17 | benefit managers on behalf of pharmacies. | ||||||
18 | (4) Provide a process by which a contracted pharmacy | ||||||
19 | can appeal the provider's reimbursement for a drug subject | ||||||
20 | to maximum allowable cost pricing. The appeals process | ||||||
21 | must, at a minimum, include the following: | ||||||
22 | (A) A requirement that a contracted pharmacy has | ||||||
23 | 14 calendar days after the applicable fill date to | ||||||
24 | appeal a maximum allowable cost if the reimbursement | ||||||
25 | for the drug is less than the net amount that the | ||||||
26 | network provider paid to the supplier of the drug. |
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1 | (B) A requirement that a pharmacy benefit manager | ||||||
2 | must respond to a challenge within 14 calendar days of | ||||||
3 | the contracted pharmacy making the claim for which the | ||||||
4 | appeal has been submitted. | ||||||
5 | (C) A telephone number and e-mail address or | ||||||
6 | website to network providers, at which the provider | ||||||
7 | can contact the pharmacy benefit manager to process | ||||||
8 | and submit an appeal. | ||||||
9 | (D) A requirement that, if an appeal is denied, | ||||||
10 | the pharmacy benefit manager must provide the reason | ||||||
11 | for the denial and the name and the national drug code | ||||||
12 | number from national or regional wholesalers. | ||||||
13 | (E) A requirement that, if an appeal is sustained, | ||||||
14 | the pharmacy benefit manager must make an adjustment | ||||||
15 | in the drug price effective the date the challenge is | ||||||
16 | resolved and make the adjustment applicable to all | ||||||
17 | similarly situated network pharmacy providers, as | ||||||
18 | determined by the managed care organization or | ||||||
19 | pharmacy benefit manager. | ||||||
20 | (5) Allow a plan sponsor contracting with a pharmacy | ||||||
21 | benefit manager an annual right to audit compliance with | ||||||
22 | the terms of the contract by the pharmacy benefit manager, | ||||||
23 | including, but not limited to, full disclosure of any and | ||||||
24 | all rebate amounts secured, whether product specific or | ||||||
25 | generalized rebates, that were provided to the pharmacy | ||||||
26 | benefit manager by a pharmaceutical manufacturer. |
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1 | (6) Allow a plan sponsor contracting with a pharmacy | ||||||
2 | benefit manager to request that the pharmacy benefit | ||||||
3 | manager disclose the actual amounts paid by the pharmacy | ||||||
4 | benefit manager to the pharmacy. | ||||||
5 | (7) Provide notice to the party contracting with the | ||||||
6 | pharmacy benefit manager of any consideration that the | ||||||
7 | pharmacy benefit manager receives from the manufacturer | ||||||
8 | for dispense as written prescriptions once a generic or | ||||||
9 | biologically similar product becomes available. | ||||||
10 | (c) In order to place a particular prescription drug on a | ||||||
11 | maximum allowable cost list, the pharmacy benefit manager | ||||||
12 | must, at a minimum, ensure that: | ||||||
13 | (1) if the drug is a generically equivalent drug, it | ||||||
14 | is listed as therapeutically equivalent and | ||||||
15 | pharmaceutically equivalent "A" or "B" rated in the United | ||||||
16 | States Food and Drug Administration's most recent version | ||||||
17 | of the "Orange Book" or have an NR or NA rating by | ||||||
18 | Medi-Span, Gold Standard, or a similar rating by a | ||||||
19 | nationally recognized reference; | ||||||
20 | (2) the drug is available for purchase by each | ||||||
21 | pharmacy in the State from national or regional | ||||||
22 | wholesalers operating in Illinois; and | ||||||
23 | (3) the drug is not obsolete. | ||||||
24 | (d) A pharmacy benefit manager is prohibited from limiting | ||||||
25 | a pharmacist's ability to disclose whether the cost-sharing | ||||||
26 | obligation exceeds the retail price for a covered prescription |
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1 | drug, and the availability of a more affordable alternative | ||||||
2 | drug, if one is available in accordance with Section 42 of the | ||||||
3 | Pharmacy Practice Act. | ||||||
4 | (e) A health insurer or pharmacy benefit manager shall not | ||||||
5 | require an insured to make a payment for a prescription drug at | ||||||
6 | the point of sale in an amount that exceeds the lesser of: | ||||||
7 | (1) the applicable cost-sharing amount; or | ||||||
8 | (2) the retail price of the drug in the absence of | ||||||
9 | prescription drug coverage. | ||||||
10 | (f) Unless required by law, a contract between a pharmacy | ||||||
11 | benefit manager or third-party payer and a 340B entity or 340B | ||||||
12 | pharmacy shall not contain any provision that: | ||||||
13 | (1) distinguishes between drugs purchased through the | ||||||
14 | 340B drug discount program and other drugs when | ||||||
15 | determining reimbursement or reimbursement methodologies, | ||||||
16 | or contains otherwise less favorable payment terms or | ||||||
17 | reimbursement methodologies for 340B entities or 340B | ||||||
18 | pharmacies when compared to similarly situated non-340B | ||||||
19 | entities; | ||||||
20 | (2) imposes any fee, chargeback, or rate adjustment | ||||||
21 | that is not similarly imposed on similarly situated | ||||||
22 | pharmacies that are not 340B entities or 340B pharmacies; | ||||||
23 | (3) imposes any fee, chargeback, or rate adjustment | ||||||
24 | that exceeds the fee, chargeback, or rate adjustment that | ||||||
25 | is not similarly imposed on similarly situated pharmacies | ||||||
26 | that are not 340B entities or 340B pharmacies; |
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1 | (4) prevents or interferes with an individual's choice | ||||||
2 | to receive a covered prescription drug from a 340B entity | ||||||
3 | or 340B pharmacy through any legally permissible means, | ||||||
4 | except that nothing in this paragraph shall prohibit the | ||||||
5 | establishment of differing copayments or other | ||||||
6 | cost-sharing amounts within the benefit plan for covered | ||||||
7 | persons who acquire covered prescription drugs from a | ||||||
8 | nonpreferred or nonparticipating provider; | ||||||
9 | (5) excludes a 340B entity or 340B pharmacy from a | ||||||
10 | pharmacy network on any basis that includes consideration | ||||||
11 | of whether the 340B entity or 340B pharmacy participates | ||||||
12 | in the 340B drug discount program; | ||||||
13 | (6) prevents a 340B entity or 340B pharmacy from using | ||||||
14 | a drug purchased under the 340B drug discount program; or | ||||||
15 | (7) any other provision that discriminates against a | ||||||
16 | 340B entity or 340B pharmacy by treating the 340B entity | ||||||
17 | or 340B pharmacy differently than non-340B entities or | ||||||
18 | non-340B pharmacies for any reason relating to the | ||||||
19 | entity's participation in the 340B drug discount program. | ||||||
20 | As used in this subsection, "pharmacy benefit manager" and | ||||||
21 | "third-party payer" do not include pharmacy benefit managers | ||||||
22 | and third-party payers acting on behalf of a Medicaid program. | ||||||
23 | (g) A violation of this Section by a pharmacy benefit | ||||||
24 | manager constitutes an unfair or deceptive act or practice in | ||||||
25 | the business of insurance under Section 424. | ||||||
26 | (h) A provision that violates subsection (f) in a contract |
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1 | between a pharmacy benefit manager or a third-party payer and | ||||||
2 | a 340B entity that is entered into, amended, or renewed after | ||||||
3 | July 1, 2022 shall be void and unenforceable. | ||||||
4 | (i)(1) A pharmacy benefit manager may not retaliate | ||||||
5 | against a pharmacist or pharmacy for disclosing information in | ||||||
6 | a court, in an administrative hearing, before a legislative | ||||||
7 | commission or committee, or in any other proceeding, if the | ||||||
8 | pharmacist or pharmacy has reasonable cause to believe that | ||||||
9 | the disclosed information is evidence of a violation of a | ||||||
10 | State or federal law, rule, or regulation. | ||||||
11 | (2) A pharmacy benefit manager may not retaliate against a | ||||||
12 | pharmacist or pharmacy for disclosing information to a | ||||||
13 | government or law enforcement agency, if the pharmacist or | ||||||
14 | pharmacy has reasonable cause to believe that the disclosed | ||||||
15 | information is evidence of a violation of a State or federal | ||||||
16 | law, rule, or regulation. | ||||||
17 | (3) A pharmacist or pharmacy shall make commercially | ||||||
18 | reasonable efforts to limit the disclosure of confidential and | ||||||
19 | proprietary information. | ||||||
20 | (4) Retaliatory actions against a pharmacy or pharmacist | ||||||
21 | include cancellation of, restriction of, or refusal to renew | ||||||
22 | or offer a contract to a pharmacy solely because the pharmacy | ||||||
23 | or pharmacist has: | ||||||
24 | (A) made disclosures of information that the | ||||||
25 | pharmacist or pharmacy has reasonable cause to believe is | ||||||
26 | evidence of a violation of a State or federal law, rule, or |
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1 | regulation; | ||||||
2 | (B) filed complaints with the plan or pharmacy benefit | ||||||
3 | manager; or | ||||||
4 | (C) filed complaints against the plan or pharmacy | ||||||
5 | benefit manager with the Department. | ||||||
6 | (j) (i) This Section applies to contracts entered into or | ||||||
7 | renewed on or after January 1, 2024 July 1, 2022 . | ||||||
8 | (k) (j) This Section applies to any group or individual | ||||||
9 | policy of accident and health insurance or managed care plan | ||||||
10 | that provides coverage for prescription drugs and that is | ||||||
11 | amended, delivered, issued, or renewed on or after July 1, | ||||||
12 | 2020.
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13 | (Source: P.A. 101-452, eff. 1-1-20; 102-778, eff. 7-1-22; | ||||||
14 | revised 8-19-22.)".
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