100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
HB4995

 

Introduced , by Rep. Fred Crespo

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/364.3 new
305 ILCS 5/5-5.12b new

    Amends the Illinois Insurance Code and the Illinois Public Aid Code. Requires that on or before July 1, 2019, the Department of Insurance and Department of Healthcare and Family Services to jointly develop a uniform prior authorization form to be used by prescribing providers to request prior authorization for prescription drug benefits. Provides that on and after January 1, 2020, or 6 months after the uniform prior authorization form is developed, whichever is later, health insurers, managed care organizations, and fee-for-service medical assistance programs that provide prescription drug benefits shall utilize and accept the uniform prior authorization form and prescribing providers may use the uniform prior authorization form. Provides criteria for developing the uniform prior authorization form. Provides requirements and limitations of prior authorization requests.


LRB100 18319 SMS 33524 b

FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4995LRB100 18319 SMS 33524 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 364.3 as follows:
 
6    (215 ILCS 5/364.3 new)
7    Sec. 364.3. Uniform prior authorization form; prescription
8benefits.
9    (a) For purposes of this Section, "prescribing provider"
10includes a provider authorized to write a prescription, as
11defined in subsection (e) of Section 3 of the Pharmacy Practice
12Act, to treat a medical condition of an insured.
13    (b) Notwithstanding any other provision of law, on and
14after January 1, 2020, or 6 months after the uniform prior
15authorization form is developed, whichever is later, a health
16insurer that provides prescription drug benefits shall utilize
17and accept the uniform prior authorization form developed
18pursuant to subsection (d) when requiring prior authorization
19for prescription drug benefits.
20    (c) If a health insurer fails to utilize or accept the
21uniform prior authorization form or fails to respond within 2
22business days after receipt of a completed prior authorization
23request from a prescribing provider, pursuant to the submission

 

 

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1of the uniform prior authorization form developed as described
2in subsection (d), the prior authorization request shall be
3deemed to have been granted.
4    (d) On or before July 1, 2019, the Department and the
5Department of Healthcare and Family Services shall jointly
6develop a uniform prior authorization form that shall be used
7by health insurers. Notwithstanding any other provision of law,
8on and after January 1, 2020, or 6 months after the uniform
9prior authorization form is developed, whichever is later,
10every prescribing provider may use that uniform prior
11authorization form to request prior authorization for coverage
12of prescription drug benefits and every health insurer shall
13accept that uniform prior authorization form as sufficient to
14request prior authorization for prescription drug benefits.
15    (e) The uniform prior authorization form developed
16pursuant to subsection (d) shall not exceed one page and shall
17be made electronically available by the Department and the
18health insurer.
19    The completed uniform prior authorization form may also be
20electronically submitted from the prescribing provider to the
21health insurer.
22    The Department and the Department of Healthcare and Family
23Services shall develop the uniform prior authorization form
24with input from interested parties, including, but not limited
25to, 2 psychiatrists recommended by a State organization that
26represents psychiatrists appointed by the President of the

 

 

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1Senate, 2 physicians recommended by a State organization that
2represents physicians appointed by the Speaker of the House of
3Representatives, 2 family physicians recommended by a State
4organization that represents family physicians appointed by
5the President of the Senate, 2 pediatricians recommended by a
6State organization that represents pediatricians appointed by
7the Speaker of the House of Representatives, from at least one
8public meeting.
9    The Department and the Department of Healthcare and Family
10Services, in development of the uniform prior authorization
11form, shall take into consideration the following:
12        (1) existing prior authorization forms established by
13    the federal Centers for Medicare and Medicaid Services and
14    the Department of Healthcare and Family Services; and
15        (2) national standards pertaining to electronic prior
16    authorization.
17    (f) The uniform prior authorization form shall not require
18any of the following information or documents:
19        (1) patient medical records;
20        (2) provider chart notes; or
21        (3) drug screens unless clinically relevant.
22    (g) Prior authorization approvals shall be effective for a
23minimum of one year.
24    (h) Providers may adjust prescription dosages within
25medically accepted ranges without requiring another prior
26authorization to change the prescription dosage.

 

 

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1    (i) Prior authorizations may not be denied because a
2prescription would be used off-label from the federal Food and
3Drug Administration formal indication if the medication is
4recommended by peer reviewed literature or in evidence-based
5practice guidelines.
6    (j) The response to an appeal of a prior authorization
7denial must be provided:
8         (1) within 24 hours for patients with urgent
9    medication needs; and
10         (2) within 5 business days for patients with regular
11    medication needs.
 
12    Section 10. The Illinois Public Aid Code is amended by
13adding Section 5-5.12b as follows:
 
14    (305 ILCS 5/5-5.12b new)
15    Sec. 5-5.12b. Uniform prior authorization form;
16prescription benefits.
17    (a) For purposes of this Section:
18    "Prescribing provider" includes a provider authorized to
19write a prescription, as defined in subsection (e) of Section 3
20of the Pharmacy Practice Act, to treat a medical condition of a
21person eligible for medical assistance.
22    "Uniform prior authorization form" means the uniform prior
23authorization form created under Section 364.3 of the Illinois
24Insurance Code.

 

 

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1    (b) Notwithstanding any other provision of law, on and
2after January 1, 2020, or 6 months after the uniform prior
3authorization form is developed, whichever is later, a managed
4care organization or fee-for-service medical assistance
5program that provides prescription drug benefits shall utilize
6and accept the uniform prior authorization form when requiring
7prior authorization for prescription drug benefits.
8    (c) If a managed care organization or fee-for-service
9medical assistance program fails to utilize or accept the
10uniform prior authorization form, or fails to respond within 2
11business days upon receipt of a completed prior authorization
12request from a prescribing provider, pursuant to the submission
13of the uniform prior authorization form, the prior
14authorization request shall be deemed to have been granted.
15    (d) Notwithstanding any other provision of law, on and
16after January 1, 2020, or 6 months after the uniform prior
17authorization form is developed, whichever is later, every
18prescribing provider may use that uniform prior authorization
19form to request prior authorization for coverage of
20prescription drug benefits and every managed care organization
21and fee-for-service medical assistance program shall accept
22that uniform prior authorization form as sufficient to request
23prior authorization for prescription drug benefits.
24    (e) The uniform prior authorization form shall be made
25electronically available by the Department and the managed care
26organization or fee-for-service medical assistance program.

 

 

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1    (f) Prior authorization approvals shall be effective for a
2minimum of one year.
3    (g) Providers may adjust prescription dosages within
4medically accepted ranges without requiring another prior
5authorization to change the prescription dosage.
6    (h) Prior authorizations may not be denied because a
7prescription would be used off-label from the federal Food and
8Drug Administration formal indication if the medication is
9recommended by peer reviewed literature or in evidence-based
10practice guidelines.
11    (i) The response to an appeal of a prior authorization
12denial must be provided:
13        (1) within 24 hours for patients with urgent medication
14    needs; and
15        (2) within 5 business days for patients with regular
16    medication needs.