Bill Text: IL SB1451 | 2015-2016 | 99th General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that smoking cessation products shall not be subject to prior approval as a result of the 4-prescription limit.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2015-03-27 - Rule 3-9(a) / Re-referred to Assignments [SB1451 Detail]

Download: Illinois-2015-SB1451-Introduced.html

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99TH GENERAL ASSEMBLY State of Illinois 2015 and 2016 SB1451 Introduced 2/20/2015, by Sen. Dan Kotowski SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that smoking cessation products shall not be subject to prior approval as a result of the 4-prescription limit.
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FISCAL NOTE ACT MAY APPLY
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
changing Section 5-5.12 as follows:
(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
Sec. 5-5.12. Pharmacy payments.
(a) Every request submitted by a pharmacy for reimbursement
under this Article for prescription drugs provided to a
recipient of aid under this Article shall include the name of
the prescriber or an acceptable identification number as
established by the Department.
(b) Pharmacies providing prescription drugs under this
Article shall be reimbursed at a rate which shall include a
professional dispensing fee as determined by the Illinois
Department, plus the current acquisition cost of the
prescription drug dispensed. The Illinois Department shall
update its information on the acquisition costs of all
prescription drugs no less frequently than every 30 days.
However, the Illinois Department may set the rate of
reimbursement for the acquisition cost, by rule, at a
percentage of the current average wholesale acquisition cost.
(c) (Blank).

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(d) The Department shall review utilization of narcotic
medications in the medical assistance program and impose
utilization controls that protect against abuse.
(e) When making determinations as to which drugs shall be
on a prior approval list, the Department shall include as part
of the analysis for this determination, the degree to which a
drug may affect individuals in different ways based on factors
including the gender of the person taking the medication.
(f) The Department shall cooperate with the Department of
Public Health and the Department of Human Services Division of
Mental Health in identifying psychotropic medications that,
when given in a particular form, manner, duration, or frequency
(including "as needed") in a dosage, or in conjunction with
other psychotropic medications to a nursing home resident or to
a resident of a facility licensed under the ID/DD Community
Care Act, may constitute a chemical restraint or an
"unnecessary drug" as defined by the Nursing Home Care Act or
Titles XVIII and XIX of the Social Security Act and the
implementing rules and regulations. The Department shall
require prior approval for any such medication prescribed for a
nursing home resident or to a resident of a facility licensed
under the ID/DD Community Care Act, that appears to be a
chemical restraint or an unnecessary drug. The Department shall
consult with the Department of Human Services Division of
Mental Health in developing a protocol and criteria for
deciding whether to grant such prior approval.

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(g) The Department may by rule provide for reimbursement of
the dispensing of a 90-day supply of a generic or brand name,
non-narcotic maintenance medication in circumstances where it
is cost effective.
(g-5) On and after July 1, 2012, the Department may require
the dispensing of drugs to nursing home residents be in a 7-day
supply or other amount less than a 31-day supply. The
Department shall pay only one dispensing fee per 31-day supply.
(h) Effective July 1, 2011, the Department shall
discontinue coverage of select over-the-counter drugs,
including analgesics and cough and cold and allergy
medications.
(h-5) On and after July 1, 2012, the Department shall
impose utilization controls, including, but not limited to,
prior approval on specialty drugs, oncolytic drugs, drugs for
the treatment of HIV or AIDS, immunosuppressant drugs, and
biological products in order to maximize savings on these
drugs. The Department may adjust payment methodologies for
non-pharmacy billed drugs in order to incentivize the selection
of lower-cost drugs. For drugs for the treatment of AIDS, the
Department shall take into consideration the potential for
non-adherence by certain populations, and shall develop
protocols with organizations or providers primarily serving
those with HIV/AIDS, as long as such measures intend to
maintain cost neutrality with other utilization management
controls such as prior approval. For hemophilia, the Department

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shall develop a program of utilization review and control which
may include, in the discretion of the Department, prior
approvals. The Department may impose special standards on
providers that dispense blood factors which shall include, in
the discretion of the Department, staff training and education;
patient outreach and education; case management; in-home
patient assessments; assay management; maintenance of stock;
emergency dispensing timeframes; data collection and
reporting; dispensing of supplies related to blood factor
infusions; cold chain management and packaging practices; care
coordination; product recalls; and emergency clinical
consultation. The Department may require patients to receive a
comprehensive examination annually at an appropriate provider
in order to be eligible to continue to receive blood factor.
(i) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(j) On and after July 1, 2012, the Department shall impose
limitations on prescription drugs such that the Department
shall not provide reimbursement for more than 4 prescriptions,
including 3 brand name prescriptions, for distinct drugs in a
30-day period, unless prior approval is received for all
prescriptions in excess of the 4-prescription limit. Drugs in
the following therapeutic classes shall not be subject to prior

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approval as a result of the 4-prescription limit:
immunosuppressant drugs, oncolytic drugs, anti-retroviral
drugs, and, on or after July 1, 2014, antipsychotic drugs.
Smoking cessation products shall not be subject to prior
approval as a result of the 4-prescription limit. On or after
July 1, 2014, the Department may exempt children with complex
medical needs enrolled in a care coordination entity contracted
with the Department to solely coordinate care for such
children, if the Department determines that the entity has a
comprehensive drug reconciliation program.
(k) No medication therapy management program implemented
by the Department shall be contrary to the provisions of the
Pharmacy Practice Act.
(l) Any provider enrolled with the Department that bills
the Department for outpatient drugs and is eligible to enroll
in the federal Drug Pricing Program under Section 340B of the
federal Public Health Services Act shall enroll in that
program. No entity participating in the federal Drug Pricing
Program under Section 340B of the federal Public Health
Services Act may exclude Medicaid from their participation in
that program, although the Department may exclude entities
defined in Section 1905(l)(2)(B) of the Social Security Act
from this requirement.
(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333,
eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12;
97-813, eff. 7-13-12; 98-463, eff. 8-16-13; 98-651, eff.

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6-16-14.)