HB3479sam002 100TH GENERAL ASSEMBLY

Sen. Andy Manar

Filed: 5/8/2018

10000HB3479sam002 LRB100 10189 KTG 39872 a

AMENDMENT TO HOUSE BILL 3479

AMENDMENT NO. ______. Amend House Bill 3479, AS AMENDED, by inserting at the end of the bill the following:

"Section 10. The Illinois Public Aid Code is amended by adding Section 5-30.8 as follows:

(305 ILCS 5/5-30.8 new)

Sec. 5-30.8. Pharmacy reimbursement rates; managed care.

(a) As used in this Section:

"Actual acquisition cost" means the listed amount for a pharmaceutical product on the pharmacy provider's billing invoice.

"Pharmacy benefits manager" means an entity that administers or manages a pharmacy benefits plan or program.

(b) The Department shall require a managed care organization, including any pharmacy benefits manager, to reimburse pharmacy providers equal to the Department's fee-for-service reimbursement rates.

(c) The reimbursement rate for prescription medications shall include a professional dispensing fee, which shall equal the fee-for-service professional dispensing fee utilized by the Department.

(d) The Department shall require a managed care organization, including any pharmacy benefits manager, to reimburse pharmacies for patient care services provided by a pharmacist at no less than 85% of the fee schedule for physician services.

(e) Any pharmacy provider may appeal the reimbursement rate for prescription medications or patient care services.

(1) The Department shall have the authority to require the managed care organization or pharmacy benefits manager to submit information to the Department related to the managed care organization's or pharmacy benefits manager's pricing methodology and rationale.

(2) The managed care organization or pharmacy benefits manager must respond to the request for information no later than 7 days after the date upon which the request is made. If the managed care organization or pharmacy benefits manager does not respond to the Department's request within 7 days after the date upon which the request is made, the Department shall render a final decision in favor of the pharmacy provider.

(f) At no time shall a pharmacy provider that contracts with a managed care organization or pharmacy benefits manager be forced to dispense any prescription medication for a reimbursement rate below the actual acquisition cost.

(g) The contracting of pharmacy providers shall be separated from any other group or national pharmacy provider contract offered by a pharmacy benefits manager.

(h) Medicaid pharmacy provider participation must remain voluntary, as under the fee-for-service medical assistance program.

(i) A pharmacy benefits manager shall not require a pharmacy provider to participate in a Medicaid managed care organization's provider network.

(j) A pharmacy provider may decline to participate in a contract with a pharmacy benefits manager and remain a fee-for-service provider.

(k) No later than January 1, 2019, the Auditor General shall initiate an audit of Medicaid managed care organizations contracted with the Department and pharmacy benefits managers contracted with Medicaid managed care organizations to determine if their reimbursement methodologies are fair and to determine the amount of Medicaid dollars retained by the pharmacy benefits managers.

Section 99. Effective date. This Section and Section 10 take effect upon becoming law.".