Bill Text: IL HB6277 | 2013-2014 | 98th General Assembly | Introduced
Bill Title: Amends the Illinois Insurance Code. Provides that a health plan that provides coverage for prescription drugs shall ensure that any required copayment or coinsurance applicable to drugs on a specialty tier does not exceed $100 per month for up to a 30-day supply of any single drug and a beneficiary's annual out-of-pocket expenditures for prescription drugs are limited to no more than fifty percent of the dollar amounts in effect under specified provisions of the federal Affordable Care Act. Provides that a health plan that provides coverage for prescription drugs and uses a tiered formulary shall implement an exceptions process that allows enrollees to request an exception to the tiered cost-sharing structure. Provides that a health plan that provides coverage for prescription drugs shall not place all drugs in a given class on a specialty tier. Effective January 1, 2015.
Spectrum: Partisan Bill (Democrat 10-0)
Status: (Failed) 2014-12-03 - Session Sine Die [HB6277 Detail]
Download: Illinois-2013-HB6277-Introduced.html
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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by adding | |||||||||||||||||||
5 | Section 356z.22 as follows:
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6 | (215 ILCS 5/356z.22 new) | |||||||||||||||||||
7 | Sec. 356z.22. Specialty tier prescription coverage. | |||||||||||||||||||
8 | (a) As used in this Section: | |||||||||||||||||||
9 | "Coinsurance" means a cost-sharing amount set as a | |||||||||||||||||||
10 | percentage of the total cost of a drug. | |||||||||||||||||||
11 | "Copayment" means a cost-sharing amount set as a dollar | |||||||||||||||||||
12 | value. | |||||||||||||||||||
13 | "Non-preferred drug" means a drug in a tier designed | |||||||||||||||||||
14 | for certain drugs deemed non-preferred and therefore | |||||||||||||||||||
15 | subject to higher cost-sharing amounts than preferred | |||||||||||||||||||
16 | drugs. | |||||||||||||||||||
17 | "Preferred drug" means a drug in a tier designed for | |||||||||||||||||||
18 | certain drugs deemed preferred and therefore subject to | |||||||||||||||||||
19 | lower cost-sharing amounts than non-preferred drugs. | |||||||||||||||||||
20 | "Specialty tier" means a tier of cost sharing that | |||||||||||||||||||
21 | imposes cost-sharing obligations that exceed that amount | |||||||||||||||||||
22 | for non-preferred and preferred drugs. | |||||||||||||||||||
23 | "Tiered formulary" means a formulary that provides |
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1 | coverage for prescription drugs as part of a health plan | ||||||
2 | for which cost sharing, deductibles, or coinsurance | ||||||
3 | obligations are determined by category or tier of | ||||||
4 | prescription drugs and includes at least 2 different tiers. | ||||||
5 | (b) A health plan that provides coverage for prescription | ||||||
6 | drugs shall ensure that: | ||||||
7 | (1) any required copayment or coinsurance applicable | ||||||
8 | to drugs on a specialty tier does not exceed $100 per month | ||||||
9 | for up to a 30-day supply of any single drug; this limit | ||||||
10 | shall be inclusive of any patient out-of-pocket spending, | ||||||
11 | including payments towards any deductibles, copayments, or | ||||||
12 | coinsurance; further this limit shall be applicable at any | ||||||
13 | point in the benefit design, including before and after any | ||||||
14 | applicable deductible is reached; and | ||||||
15 | (2) a beneficiary's annual out-of-pocket expenditures | ||||||
16 | for prescription drugs are limited to no more than 50% of | ||||||
17 | the dollar amounts in effect under Section 1302(c)(1) of | ||||||
18 | the federal Affordable Care Act for self-only and family | ||||||
19 | coverage, respectively. | ||||||
20 | (c) A health plan that provides coverage for prescription | ||||||
21 | drugs and uses a tiered formulary shall implement an exceptions | ||||||
22 | process that allows enrollees to request an exception to the | ||||||
23 | tiered cost-sharing structure. Under an exception, a | ||||||
24 | non-preferred drug may be covered under the cost sharing | ||||||
25 | applicable for preferred drugs if the prescribing health care | ||||||
26 | provider determines that the preferred drug for treatment of |
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1 | the same condition either would not be as effective for the | ||||||
2 | individual, would have adverse effects for the individual, or | ||||||
3 | both. If an enrollee is denied a cost-sharing exception, the | ||||||
4 | denial shall be considered an adverse event and shall be | ||||||
5 | subject to the health plan's internal review process. | ||||||
6 | (d) A health plan that provides coverage for prescription | ||||||
7 | drugs shall not place all drugs in a given class on a specialty | ||||||
8 | tier. | ||||||
9 | (e) Nothing in this Section shall be construed to require a | ||||||
10 | health plan to: | ||||||
11 | (1) provide coverage for any additional drugs not | ||||||
12 | otherwise required by law; | ||||||
13 | (2) implement specific utilization management | ||||||
14 | techniques, such as prior authorization or step therapy; or | ||||||
15 | (3) cease utilization of tiered cost-sharing | ||||||
16 | structures, including those strategies used to incentivize | ||||||
17 | use of preventive services, disease management, and | ||||||
18 | low-cost treatment options. | ||||||
19 | (f) Nothing in this Section shall be construed to require a | ||||||
20 | pharmacist to substitute a drug without the consent of the | ||||||
21 | prescribing physician. | ||||||
22 | (g) The Director shall adopt rules outlining the | ||||||
23 | enforcement processes for this Section.
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24 | Section 99. Effective date. This Act takes effect January | ||||||
25 | 1, 2015.
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