Bill Text: IL SB1359 | 2015-2016 | 99th General Assembly | Introduced

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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 Patient Protection 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, 2016.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced - Dead) 2015-10-10 - Senate Committee Amendment No. 1 Pursuant to Senate Rule 3-9(b) / Referred to Assignments [SB1359 Detail]

Download: Illinois-2015-SB1359-Introduced.html

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99TH GENERAL ASSEMBLY State of Illinois 2015 and 2016 SB1359 Introduced 2/18/2015, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.23 new
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 Patient Protection 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, 2016.
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A BILL FOR
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AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by adding
Section 356z.23 as follows:
(215 ILCS 5/356z.23 new)
Sec. 356z.23. Specialty tier prescription coverage.
(a) As used in this Section:
"Coinsurance" means a cost-sharing amount set as a
percentage of the total cost of a drug.
"Copayment" means a cost-sharing amount set as a dollar
value.
"Non-preferred drug" means a drug in a tier designed
for certain drugs deemed non-preferred and therefore
subject to higher cost-sharing amounts than preferred
drugs.
"Preferred drug" means a drug in a tier designed for
certain drugs deemed preferred and therefore subject to
lower cost-sharing amounts than non-preferred drugs.
"Specialty tier" means a tier of cost sharing that
imposes cost-sharing obligations that exceed that amount
for non-preferred and preferred drugs.
"Tiered formulary" means a formulary that provides

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coverage for prescription drugs as part of a health plan
for which cost sharing, deductibles, or coinsurance
obligations are determined by category or tier of
prescription drugs and includes at least 2 different tiers.
(b) A health plan that provides coverage for prescription
drugs shall ensure that:
(1) 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; this limit
shall be inclusive of any patient out-of-pocket spending,
including payments towards any deductibles, copayments, or
coinsurance; further this limit shall be applicable at any
point in the benefit design, including before and after any
applicable deductible is reached; and
(2) a beneficiary's annual out-of-pocket expenditures
for prescription drugs are limited to no more than 50% of
the dollar amounts in effect under Section 1302(c)(1) of
the federal Affordable Care Act for self-only and family
coverage, respectively.
(c) 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. Under an exception, a
non-preferred drug may be covered under the cost sharing
applicable for preferred drugs if the prescribing health care
provider determines that the preferred drug for treatment of

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the same condition either would not be as effective for the
individual, would have adverse effects for the individual, or
both. If an enrollee is denied a cost-sharing exception, the
denial shall be considered an adverse event and shall be
subject to the health plan's internal review process.
(d) A health plan that provides coverage for prescription
drugs shall not place all drugs in a given class on a specialty
tier.
(e) Nothing in this Section shall be construed to require a
health plan to:
(1) provide coverage for any additional drugs not
otherwise required by law;
(2) implement specific utilization management
techniques, such as prior authorization or step therapy; or
(3) cease utilization of tiered cost-sharing
structures, including those strategies used to incentivize
use of preventive services, disease management, and
low-cost treatment options.
(f) Nothing in this Section shall be construed to require a
pharmacist to substitute a drug without the consent of the
prescribing physician.
(g) The Director shall adopt rules outlining the
enforcement processes for this Section.
Section 99. Effective date. This Act takes effect January
1, 2016.