Bill Text: IL SB3395 | 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 (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 and (2) required copayment or coinsurance for drugs on a specialty tier does not exceed, in the aggregate for those specialty tier covered drugs, $200 per month per enrollee. Provides that a health plan that provides coverage for prescription drugs and utilizes a tiered formulary shall implement an exceptions process that allows enrollees to request an exception to the tiered cost-sharing structure. Makes other changes. Effective January 1, 2015.
Spectrum: Partisan Bill (Democrat 8-0)
Status: (Failed) 2015-01-13 - Session Sine Die [SB3395 Detail]
Download: Illinois-2013-SB3395-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) 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 for | |||||||||||||||||||
14 | certain drugs deemed non-preferred and therefore subject to | |||||||||||||||||||
15 | higher cost-sharing amounts than preferred drugs. | |||||||||||||||||||
16 | "Preferred drug" means a drug in a tier designed for | |||||||||||||||||||
17 | certain drugs deemed preferred and therefore subject to lower | |||||||||||||||||||
18 | cost-sharing amounts than non-preferred drugs. | |||||||||||||||||||
19 | "Specialty tier" means a tier of cost sharing designed for | |||||||||||||||||||
20 | select specialty drugs that imposes cost-sharing obligations | |||||||||||||||||||
21 | that exceed that amount for non-preferred brand-name drugs or | |||||||||||||||||||
22 | their equivalent (for brand-name drugs if there is no | |||||||||||||||||||
23 | non-preferred brand-name drug category) and such a |
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1 | cost-sharing amount is based on a coinsurance. | ||||||
2 | "Tiered formulary" means a formulary that provides | ||||||
3 | coverage for prescription drugs as part of a health plan for | ||||||
4 | which cost sharing, deductibles, or coinsurance obligations | ||||||
5 | are determined by category or tier of prescription drugs and | ||||||
6 | includes at least 2 different tiers. | ||||||
7 | (b) A health plan that provides coverage for prescription | ||||||
8 | drugs shall ensure that: | ||||||
9 | (1) any required copayment or coinsurance applicable | ||||||
10 | to drugs on a specialty tier does not exceed $100 per month | ||||||
11 | for up to a 30-day supply of any single drug; and | ||||||
12 | (2) any required copayment or coinsurance for drugs on | ||||||
13 | a specialty tier does not exceed, in the aggregate for | ||||||
14 | those specialty tier covered drugs, $200 per month per | ||||||
15 | enrollee. | ||||||
16 | (c) A health plan that provides coverage for prescription | ||||||
17 | drugs and utilizes a tiered formulary shall implement an | ||||||
18 | exceptions process that allows enrollees to request an | ||||||
19 | exception to the tiered cost-sharing structure. Under such an | ||||||
20 | exception, a non-preferred drug may be covered under the cost | ||||||
21 | sharing applicable for preferred drugs if the prescribing | ||||||
22 | physician determines that the preferred drug for treatment of | ||||||
23 | the same condition either would not be as effective for the | ||||||
24 | individual or would have adverse effects for the individual, or | ||||||
25 | both. In the event an enrollee is denied a cost-sharing | ||||||
26 | exception, the denial shall be considered an adverse event and |
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1 | shall be subject to the health plan's internal review process. | ||||||
2 | (d) A health plan that provides coverage for prescription | ||||||
3 | drugs is prohibited from placing all drugs in a given class on | ||||||
4 | a specialty tier. | ||||||
5 | (e) Nothing in this Section shall be construed to require a | ||||||
6 | health plan to: | ||||||
7 | (1) provide coverage for any additional drugs not | ||||||
8 | otherwise required by law; | ||||||
9 | (2) implement specific utilization management | ||||||
10 | techniques, such as prior authorization or step therapy; or | ||||||
11 | (3) cease utilization of tiered cost-sharing | ||||||
12 | structures, including those strategies used to incent use | ||||||
13 | of preventive services, disease management, and low-cost | ||||||
14 | treatment options. | ||||||
15 | (f) Nothing in this Section shall be construed to require a | ||||||
16 | pharmacist to substitute a drug without the consent of the | ||||||
17 | prescribing physician. | ||||||
18 | (g) The Director shall adopt rules outlining the | ||||||
19 | enforcement processes for this Section.
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20 | Section 99. Effective date. This Act takes effect January | ||||||
21 | 1, 2015.
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