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| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB3395 Introduced 2/14/2014, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED:
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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.
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| | A BILL FOR |
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| | SB3395 | | LRB098 20278 RPM 55691 b |
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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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