Bill Text: IL SB3741 | 2019-2020 | 101st General Assembly | Introduced
Bill Title: Amends the Illinois Insurance Code. Prohibits a pharmacy benefit manager from requiring that a covered prescription drug be filled by a mail-order pharmacy as a condition for reimbursement of the cost of the prescription drug. Effective immediately.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Failed) 2021-01-13 - Session Sine Die [SB3741 Detail]
Download: Illinois-2019-SB3741-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 | |||||||||||||||||||
5 | changing Section 513b1 as follows:
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6 | (215 ILCS 5/513b1) | |||||||||||||||||||
7 | Sec. 513b1. Pharmacy benefit manager contracts. | |||||||||||||||||||
8 | (a) As used in this Section: | |||||||||||||||||||
9 | "Biological product" has the meaning ascribed to that term | |||||||||||||||||||
10 | in Section 19.5 of the Pharmacy Practice Act. | |||||||||||||||||||
11 | "Maximum allowable cost" means the maximum amount that a | |||||||||||||||||||
12 | pharmacy benefit manager will reimburse a pharmacy for the cost | |||||||||||||||||||
13 | of a drug. | |||||||||||||||||||
14 | "Maximum allowable cost list" means a list of drugs for | |||||||||||||||||||
15 | which a maximum allowable cost has been established by a | |||||||||||||||||||
16 | pharmacy benefit manager. | |||||||||||||||||||
17 | "Pharmacy benefit manager" means a person, business, or | |||||||||||||||||||
18 | entity, including a wholly or partially owned or controlled | |||||||||||||||||||
19 | subsidiary of a pharmacy benefit manager, that provides claims | |||||||||||||||||||
20 | processing services or other prescription drug or device | |||||||||||||||||||
21 | services, or both, for health benefit plans. | |||||||||||||||||||
22 | "Retail price" means the price an individual without | |||||||||||||||||||
23 | prescription drug coverage would pay at a retail pharmacy, not |
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1 | including a pharmacist dispensing fee. | ||||||
2 | (b) A contract between a health insurer and a pharmacy | ||||||
3 | benefit manager must require that the pharmacy benefit manager: | ||||||
4 | (1) Update maximum allowable cost pricing information | ||||||
5 | at least every 7 calendar days. | ||||||
6 | (2) Maintain a process that will, in a timely manner, | ||||||
7 | eliminate drugs from maximum allowable cost lists or modify | ||||||
8 | drug prices to remain consistent with changes in pricing | ||||||
9 | data used in formulating maximum allowable cost prices and | ||||||
10 | product availability. | ||||||
11 | (3) Provide access to its maximum allowable cost list | ||||||
12 | to each pharmacy or pharmacy services administrative | ||||||
13 | organization subject to the maximum allowable cost list. | ||||||
14 | Access may include a real-time pharmacy website portal to | ||||||
15 | be able to view the maximum allowable cost list. As used in | ||||||
16 | this Section, "pharmacy services administrative | ||||||
17 | organization" means an entity operating within the State | ||||||
18 | that contracts with independent pharmacies to conduct | ||||||
19 | business on their behalf with third-party payers. A | ||||||
20 | pharmacy services administrative organization may provide | ||||||
21 | administrative services to pharmacies and negotiate and | ||||||
22 | enter into contracts with third-party payers or pharmacy | ||||||
23 | benefit managers on behalf of pharmacies. | ||||||
24 | (4) Provide a process by which a contracted pharmacy | ||||||
25 | can appeal the provider's reimbursement for a drug subject | ||||||
26 | to maximum allowable cost pricing. The appeals process |
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1 | must, at a minimum, include the following: | ||||||
2 | (A) A requirement that a contracted pharmacy has 14 | ||||||
3 | calendar days after the applicable fill date to appeal | ||||||
4 | a maximum allowable cost if the reimbursement for the | ||||||
5 | drug is less than the net amount that the network | ||||||
6 | provider paid to the supplier of the drug. | ||||||
7 | (B) A requirement that a pharmacy benefit manager | ||||||
8 | must respond to a challenge within 14 calendar days of | ||||||
9 | the contracted pharmacy making the claim for which the | ||||||
10 | appeal has been submitted. | ||||||
11 | (C) A telephone number and e-mail address or | ||||||
12 | website to network providers, at which the provider can | ||||||
13 | contact the pharmacy benefit manager to process and | ||||||
14 | submit an appeal. | ||||||
15 | (D) A requirement that, if an appeal is denied, the | ||||||
16 | pharmacy benefit manager must provide the reason for | ||||||
17 | the denial and the name and the national drug code | ||||||
18 | number from national or regional wholesalers. | ||||||
19 | (E) A requirement that, if an appeal is sustained, | ||||||
20 | the pharmacy benefit manager must make an adjustment in | ||||||
21 | the drug price effective the date the challenge is | ||||||
22 | resolved and make the adjustment applicable to all | ||||||
23 | similarly situated network pharmacy providers, as | ||||||
24 | determined by the managed care organization or | ||||||
25 | pharmacy benefit manager. | ||||||
26 | (5) Allow a plan sponsor contracting with a pharmacy |
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1 | benefit manager an annual right to audit compliance with | ||||||
2 | the terms of the contract by the pharmacy benefit manager, | ||||||
3 | including, but not limited to, full disclosure of any and | ||||||
4 | all rebate amounts secured, whether product specific or | ||||||
5 | generalized rebates, that were provided to the pharmacy | ||||||
6 | benefit manager by a pharmaceutical manufacturer. | ||||||
7 | (6) Allow a plan sponsor contracting with a pharmacy | ||||||
8 | benefit manager to request that the pharmacy benefit | ||||||
9 | manager disclose the actual amounts paid by the pharmacy | ||||||
10 | benefit manager to the pharmacy. | ||||||
11 | (7) Provide notice to the party contracting with the | ||||||
12 | pharmacy benefit manager of any consideration that the | ||||||
13 | pharmacy benefit manager receives from the manufacturer | ||||||
14 | for dispense as written prescriptions once a generic or | ||||||
15 | biologically similar product becomes available. | ||||||
16 | (c) In order to place a particular prescription drug on a | ||||||
17 | maximum allowable cost list, the pharmacy benefit manager must, | ||||||
18 | at a minimum, ensure that: | ||||||
19 | (1) if the drug is a generically equivalent drug, it is | ||||||
20 | listed as therapeutically equivalent and pharmaceutically | ||||||
21 | equivalent "A" or "B" rated in the United States Food and | ||||||
22 | Drug Administration's most recent version of the "Orange | ||||||
23 | Book" or have an NR or NA rating by Medi-Span, Gold | ||||||
24 | Standard, or a similar rating by a nationally recognized | ||||||
25 | reference; | ||||||
26 | (2) the drug is available for purchase by each pharmacy |
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1 | in the State from national or regional wholesalers | ||||||
2 | operating in Illinois; and | ||||||
3 | (3) the drug is not obsolete. | ||||||
4 | (d) A pharmacy benefit manager is prohibited from limiting | ||||||
5 | a pharmacist's ability to disclose whether the cost-sharing | ||||||
6 | obligation exceeds the retail price for a covered prescription | ||||||
7 | drug, and the availability of a more affordable alternative | ||||||
8 | drug, if one is available in accordance with Section 42 of the | ||||||
9 | Pharmacy Practice Act. | ||||||
10 | (d-5) A pharmacy benefit manager is prohibited from | ||||||
11 | requiring that a covered prescription drug be filled by a | ||||||
12 | mail-order pharmacy as a condition for reimbursement of the | ||||||
13 | cost of the prescription drug. | ||||||
14 | (e) A health insurer or pharmacy benefit manager shall not | ||||||
15 | require an insured to make a payment for a prescription drug at | ||||||
16 | the point of sale in an amount that exceeds the lesser of: | ||||||
17 | (1) the applicable cost-sharing amount; or | ||||||
18 | (2) the retail price of the drug in the absence of | ||||||
19 | prescription drug coverage. | ||||||
20 | (f) This Section applies to contracts entered into or | ||||||
21 | renewed on or after the effective date of this amendatory Act | ||||||
22 | of the 101st General Assembly July 1, 2020 . | ||||||
23 | (g) This Section applies to any group or individual policy | ||||||
24 | of accident and health insurance or managed care plan that | ||||||
25 | provides coverage for prescription drugs and that is amended, | ||||||
26 | delivered, issued, or renewed on or after the effective date of |
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1 | this amendatory Act of the 101st General Assembly July 1, 2020 .
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2 | (Source: P.A. 101-452, eff. 1-1-20 .)
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3 | Section 99. Effective date. This Act takes effect upon | ||||||
4 | becoming law.
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