HB4995 100TH GENERAL ASSEMBLY

LRB100 18319 SMS 33524 b

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.

FISCAL NOTE ACT MAY APPLY

A BILL FOR

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by adding Section 364.3 as follows:

(215 ILCS 5/364.3 new)

Sec. 364.3. Uniform prior authorization form; prescription benefits.

(a) For purposes of this Section, "prescribing provider" includes a provider authorized to write a prescription, as defined in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.

(b) Notwithstanding any other provision of law, on and after January 1, 2020, or 6 months after the uniform prior authorization form is developed, whichever is later, a health insurer that provides prescription drug benefits shall utilize and accept the uniform prior authorization form developed pursuant to subsection (d) when requiring prior authorization for prescription drug benefits.

(c) If a health insurer fails to utilize or accept the uniform prior authorization form or fails to respond within 2 business days after receipt of a completed prior authorization request from a prescribing provider, pursuant to the submission of the uniform prior authorization form developed as described in subsection (d), the prior authorization request shall be deemed to have been granted.

(d) On or before July 1, 2019, the Department and the Department of Healthcare and Family Services shall jointly develop a uniform prior authorization form that shall be used by health insurers. Notwithstanding any other provision of law, on and after January 1, 2020, or 6 months after the uniform prior authorization form is developed, whichever is later, every prescribing provider may use that uniform prior authorization form to request prior authorization for coverage of prescription drug benefits and every health insurer shall accept that uniform prior authorization form as sufficient to request prior authorization for prescription drug benefits.

(e) The uniform prior authorization form developed pursuant to subsection (d) shall not exceed one page and shall be made electronically available by the Department and the health insurer.

The completed uniform prior authorization form may also be electronically submitted from the prescribing provider to the health insurer.

The Department and the Department of Healthcare and Family Services shall develop the uniform prior authorization form with input from interested parties, including, but not limited to, 2 psychiatrists recommended by a State organization that represents psychiatrists appointed by the President of the Senate, 2 physicians recommended by a State organization that represents physicians appointed by the Speaker of the House of Representatives, 2 family physicians recommended by a State organization that represents family physicians appointed by the President of the Senate, 2 pediatricians recommended by a State organization that represents pediatricians appointed by the Speaker of the House of Representatives, from at least one public meeting.

The Department and the Department of Healthcare and Family Services, in development of the uniform prior authorization form, shall take into consideration the following:

(1) existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the Department of Healthcare and Family Services; and

(2) national standards pertaining to electronic prior authorization.

(f) The uniform prior authorization form shall not require any of the following information or documents:

(1) patient medical records;

(2) provider chart notes; or

(3) drug screens unless clinically relevant.

(g) Prior authorization approvals shall be effective for a minimum of one year.

(h) Providers may adjust prescription dosages within medically accepted ranges without requiring another prior authorization to change the prescription dosage.

(i) Prior authorizations may not be denied because a prescription would be used off-label from the federal Food and Drug Administration formal indication if the medication is recommended by peer reviewed literature or in evidence-based practice guidelines.

(j) The response to an appeal of a prior authorization denial must be provided:

(1) within 24 hours for patients with urgent medication needs; and

(2) within 5 business days for patients with regular medication needs.

Section 10. The Illinois Public Aid Code is amended by adding Section 5-5.12b as follows:

(305 ILCS 5/5-5.12b new)

Sec. 5-5.12b. Uniform prior authorization form; prescription benefits.

(a) For purposes of this Section:

"Prescribing provider" includes a provider authorized to write a prescription, as defined in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of a person eligible for medical assistance.

"Uniform prior authorization form" means the uniform prior authorization form created under Section 364.3 of the Illinois Insurance Code.

(b) Notwithstanding any other provision of law, on and after January 1, 2020, or 6 months after the uniform prior authorization form is developed, whichever is later, a managed care organization or fee-for-service medical assistance program that provides prescription drug benefits shall utilize and accept the uniform prior authorization form when requiring prior authorization for prescription drug benefits.

(c) If a managed care organization or fee-for-service medical assistance program fails to utilize or accept the uniform prior authorization form, or fails to respond within 2 business days upon receipt of a completed prior authorization request from a prescribing provider, pursuant to the submission of the uniform prior authorization form, the prior authorization request shall be deemed to have been granted.

(d) Notwithstanding any other provision of law, on and after January 1, 2020, or 6 months after the uniform prior authorization form is developed, whichever is later, every prescribing provider may use that uniform prior authorization form to request prior authorization for coverage of prescription drug benefits and every managed care organization and fee-for-service medical assistance program shall accept that uniform prior authorization form as sufficient to request prior authorization for prescription drug benefits.

(e) The uniform prior authorization form shall be made electronically available by the Department and the managed care organization or fee-for-service medical assistance program.

(f) Prior authorization approvals shall be effective for a minimum of one year.

(g) Providers may adjust prescription dosages within medically accepted ranges without requiring another prior authorization to change the prescription dosage.

(h) Prior authorizations may not be denied because a prescription would be used off-label from the federal Food and Drug Administration formal indication if the medication is recommended by peer reviewed literature or in evidence-based practice guidelines.

(i) The response to an appeal of a prior authorization denial must be provided:

(1) within 24 hours for patients with urgent medication needs; and

(2) within 5 business days for patients with regular medication needs.