Bill Text: IL SB1589 | 2021-2022 | 102nd General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall provide coverage for anti-epileptic drugs. Provides that coverage for anti-epileptic drugs may not impose a waiting period or any deductible, coinsurance, copayment, or other cost-sharing limitation. Defines "anti-epileptic drug", "epilepsy", and "seizure". Amends the Managed Care Reform and Patient Rights Act. Provides that anti-seizure prescription drugs may not be substituted with a generic drug under provisions of the Pharmacy Practice Act under which a pharmacist may substitute a therapeutically equivalent generic drug for a prescription drug. Amends the Pharmacy Practice Act. Provides that a pharmacist may not interchange an anti-epileptic drug or formulation of an anti-epileptic drug for the treatment of epilepsy. Provides that a prescribing physician shall document that such anti-epileptic drug or formulation of an anti-epileptic drug for the treatment of epilepsy is clinically necessary for the patient's optimal care. Removes provisions concerning notification and consent required when a physician substitutes a generic prescription in place of a brand-name anti-epileptic drug.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2021-04-16 - Rule 3-9(a) / Re-referred to Assignments [SB1589 Detail]

Download: Illinois-2021-SB1589-Introduced.html

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102ND GENERAL ASSEMBLY State of Illinois 2021 and 2022 SB1589 Introduced 2/26/2021, by Sen. Laura Fine SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.43 new
215 ILCS 134/25
225 ILCS 85/26
Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall provide coverage for anti-epileptic drugs. Provides that coverage for anti-epileptic drugs may not impose a waiting period or any deductible, coinsurance, copayment, or other cost-sharing limitation. Defines "anti-epileptic drug", "epilepsy", and "seizure". Amends the Managed Care Reform and Patient Rights Act. Provides that anti-seizure prescription drugs may not be substituted with a generic drug under provisions of the Pharmacy Practice Act under which a pharmacist may substitute a therapeutically equivalent generic drug for a prescription drug. Amends the Pharmacy Practice Act. Provides that a pharmacist may not interchange an anti-epileptic drug or formulation of an anti-epileptic drug for the treatment of epilepsy. Provides that a prescribing physician shall document that such anti-epileptic drug or formulation of an anti-epileptic drug for the treatment of epilepsy is clinically necessary for the patient's optimal care. Removes provisions concerning notification and consent required when a physician substitutes a generic prescription in place of a brand-name anti-epileptic drug.
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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.43 as follows:
(215 ILCS 5/356z.43 new)
Sec. 356z.43. Coverage of anti-seizure prescription drugs.
(a) The General Assembly finds that this Section is
necessary for the immediate preservation of public peace,
health, and safety.
(b) In this Section:
"Anti-epileptic drug" means (i) a drug prescribed for the
treatment of epilepsy or (ii) a drug used to treat or prevent
seizures.
"Epilepsy" means a neurological condition characterized by
recurrent seizures.
"Seizure" means a brief disturbance in the electrical
activity of the brain.
(c) An individual or group policy of accident and health
insurance amended, delivered, issued, or renewed in this State
after the effective date of this amendatory Act of the 102nd
General Assembly shall provide coverage for anti-epileptic
drugs.

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(d) Coverage required under this Section may not impose a
waiting period or any deductible, coinsurance, copayment, or
other cost-sharing limitation that is greater than that
required for other coverage under the policy.
Section 10. The Managed Care Reform and Patient Rights Act
is amended by changing Section 25 as follows:
(215 ILCS 134/25)
Sec. 25. Transition of services.
(a) A health care plan shall provide for continuity of
care for its enrollees as follows:
(1) If an enrollee's physician leaves the health care
plan's network of health care providers for reasons other
than termination of a contract in situations involving
imminent harm to a patient or a final disciplinary action
by a State licensing board and the physician remains
within the health care plan's service area, the health
care plan shall permit the enrollee to continue an ongoing
course of treatment with that physician during a
transitional period:
(A) of 90 days from the date of the notice of
physician's termination from the health care plan to
the enrollee of the physician's disaffiliation from
the health care plan if the enrollee has an ongoing
course of treatment; or

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(B) if the enrollee has entered the third
trimester of pregnancy at the time of the physician's
disaffiliation, that includes the provision of
post-partum care directly related to the delivery.
(2) Notwithstanding the provisions in item (1) of this
subsection, such care shall be authorized by the health
care plan during the transitional period only if the
physician agrees:
(A) to continue to accept reimbursement from the
health care plan at the rates applicable prior to the
start of the transitional period;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health
care plan necessary medical information related to
such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures, including but not limited to
procedures regarding referrals and obtaining
preauthorizations for treatment.
(3) During an enrollee's plan year, a health care plan
shall not remove a drug from its formulary or negatively
change its preferred or cost-tier sharing unless, at least
60 days before making the formulary change, the health
care plan:
(A) provides general notification of the change in
its formulary to current and prospective enrollees;

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(B) directly notifies enrollees currently
receiving coverage for the drug, including information
on the specific drugs involved and the steps they may
take to request coverage determinations and
exceptions, including a statement that a certification
of medical necessity by the enrollee's prescribing
provider will result in continuation of coverage at
the existing level; and
(C) directly notifies by first class mail and
through an electronic transmission, if available, the
prescribing provider of all health care plan enrollees
currently prescribed the drug affected by the proposed
change; the notice shall include a one-page form by
which the prescribing provider can notify the health
care plan by first class mail that coverage of the drug
for the enrollee is medically necessary.
The notification in paragraph (C) may direct the
prescribing provider to an electronic portal through which
the prescribing provider may electronically file a
certification to the health care plan that coverage of the
drug for the enrollee is medically necessary. The
prescribing provider may make a secure electronic
signature beside the words "certification of medical
necessity", and this certification shall authorize
continuation of coverage for the drug.
If the prescribing provider certifies to the health

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care plan either in writing or electronically that the
drug is medically necessary for the enrollee as provided
in paragraph (C), a health care plan shall authorize
coverage for the drug prescribed based solely on the
prescribing provider's assertion that coverage is
medically necessary, and the health care plan is
prohibited from making modifications to the coverage
related to the covered drug, including, but not limited
to:
(i) increasing the out-of-pocket costs for the
covered drug;
(ii) moving the covered drug to a more restrictive
tier; or
(iii) denying an enrollee coverage of the drug for
which the enrollee has been previously approved for
coverage by the health care plan.
Nothing in this item (3) prevents a health care plan
from removing a drug from its formulary or denying an
enrollee coverage if the United States Food and Drug
Administration has issued a statement about the drug that
calls into question the clinical safety of the drug, the
drug manufacturer has notified the United States Food and
Drug Administration of a manufacturing discontinuance or
potential discontinuance of the drug as required by
Section 506C of the Federal Food, Drug, and Cosmetic Act,
as codified in 21 U.S.C. 356c, or the drug manufacturer

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has removed the drug from the market.
Nothing in this item (3) prohibits a health care plan,
by contract, written policy or procedure, or any other
agreement or course of conduct, from requiring a
pharmacist to effect substitutions of prescription drugs
consistent with Section 19.5 of the Pharmacy Practice Act,
under which a pharmacist may substitute an interchangeable
biologic for a prescribed biologic product, and Section 25
of the Pharmacy Practice Act, under which a pharmacist may
select a generic drug determined to be therapeutically
equivalent by the United States Food and Drug
Administration and in accordance with the Illinois Food,
Drug and Cosmetic Act, with the exception of anti-seizure
prescription drugs, which may not be substituted with a
generic drug.
This item (3) applies to a policy or contract that is
amended, delivered, issued, or renewed on or after January
1, 2019. This item (3) does not apply to a health plan as
defined in the State Employees Group Insurance Act of 1971
or medical assistance under Article V of the Illinois
Public Aid Code.
(b) A health care plan shall provide for continuity of
care for new enrollees as follows:
(1) If a new enrollee whose physician is not a member
of the health care plan's provider network, but is within
the health care plan's service area, enrolls in the health

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care plan, the health care plan shall permit the enrollee
to continue an ongoing course of treatment with the
enrollee's current physician during a transitional period:
(A) of 90 days from the effective date of
enrollment if the enrollee has an ongoing course of
treatment; or
(B) if the enrollee has entered the third
trimester of pregnancy at the effective date of
enrollment, that includes the provision of post-partum
care directly related to the delivery.
(2) If an enrollee elects to continue to receive care
from such physician pursuant to item (1) of this
subsection, such care shall be authorized by the health
care plan for the transitional period only if the
physician agrees:
(A) to accept reimbursement from the health care
plan at rates established by the health care plan;
such rates shall be the level of reimbursement
applicable to similar physicians within the health
care plan for such services;
(B) to adhere to the health care plan's quality
assurance requirements and to provide to the health
care plan necessary medical information related to
such care; and
(C) to otherwise adhere to the health care plan's
policies and procedures including, but not limited to

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procedures regarding referrals and obtaining
preauthorization for treatment.
(c) In no event shall this Section be construed to require
a health care plan to provide coverage for benefits not
otherwise covered or to diminish or impair preexisting
condition limitations contained in the enrollee's contract. In
no event shall this Section be construed to prohibit the
addition of prescription drugs to a health care plan's list of
covered drugs during the coverage year.
(Source: P.A. 100-1052, eff. 8-24-18.)
Section 15. The Pharmacy Practice Act is amended by
changing Section 26 as follows:
(225 ILCS 85/26)
(Section scheduled to be repealed on January 1, 2023)
Sec. 26. Anti-epileptic drug product selection prohibited.
(a) The General Assembly finds that this Section is
necessary for the immediate preservation of the public peace,
health, and safety.
(b) In this Section:
"Anti-epileptic drug" means (i) any drug prescribed for
the treatment of epilepsy or (ii) a drug used to treat or
prevent seizures.
"Epilepsy" means a neurological condition characterized by
recurrent seizures.

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"Seizure" means a brief disturbance in the electrical
activity of the brain.
(c) A When the prescribing physician has indicated on the
original prescription "may not substitute", a pharmacist may
not interchange an anti-epileptic drug or formulation of an
anti-epileptic drug for the treatment of epilepsy. The
prescribing physician shall document that such anti-epileptic
drug or formulation of an anti-epileptic drug for the
treatment of epilepsy is clinically necessary for the
patient's optimal care without notification and the documented
consent of the prescribing physician and the patient or the
patient's parent, legal guardian, or spouse. This Section does
not apply to medication orders issued for anti-epileptic drugs
for any in-patient care in a licensed hospital.
(d) (Blank). If a pharmacist substitutes any generic
prescription in place of a brand-name anti-epileptic drug,
then the pharmacist shall provide written notice to the
patient no later than the time the prescription is dispensed.
(Source: P.A. 97-456, eff. 1-1-12.)