101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB3543

 

Introduced 2/14/2020, by Sen. Andy Manar

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5.12  from Ch. 23, par. 5-5.12
305 ILCS 5/5-36

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires all Medicaid managed care organizations to reimburse pharmacy provider dispensing fees and acquisition costs at no less than the amounts established under the fee-for-service program whether the Medicaid managed care organization directly reimburses pharmacy providers or contracts with a pharmacy benefit manager to reimburse pharmacy providers. Provides that the reimbursement requirement applies to all pharmacy services for persons receiving benefits under the Code including pharmacy services. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB3543LRB101 18066 KTG 67504 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Sections 5-5.12 and 5-36 as follows:
 
6    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
7    Sec. 5-5.12. Pharmacy payments.
8    (a) Every request submitted by a pharmacy for reimbursement
9under this Article for prescription drugs provided to a
10recipient of aid under this Article shall include the name of
11the prescriber or an acceptable identification number as
12established by the Department.
13    (b) Pharmacies providing prescription drugs under this
14Article shall be reimbursed at a rate which shall include a
15professional dispensing fee as determined by the Illinois
16Department, plus the current acquisition cost of the
17prescription drug dispensed. The Illinois Department shall
18update its information on the acquisition costs of all
19prescription drugs no less frequently than every 30 days.
20However, the Illinois Department may set the rate of
21reimbursement for the acquisition cost, by rule, at a
22percentage of the current average wholesale acquisition cost.
23    All Medicaid managed care organizations must reimburse

 

 

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1pharmacy provider dispensing fees and acquisition costs at no
2less than the amounts established under the fee-for-service
3program whether the Medicaid managed care organization
4directly reimburses pharmacy providers or contracts with a
5pharmacy benefit manager to reimburse pharmacy providers. The
6reimbursement requirement specified in this paragraph applies
7to all pharmacy services for persons receiving benefits under
8this Code including services reimbursed under Section 5-36.
9    (c) (Blank).
10    (d) The Department shall review utilization of narcotic
11medications in the medical assistance program and impose
12utilization controls that protect against abuse.
13    (e) When making determinations as to which drugs shall be
14on a prior approval list, the Department shall include as part
15of the analysis for this determination, the degree to which a
16drug may affect individuals in different ways based on factors
17including the gender of the person taking the medication.
18    (f) The Department shall cooperate with the Department of
19Public Health and the Department of Human Services Division of
20Mental Health in identifying psychotropic medications that,
21when given in a particular form, manner, duration, or frequency
22(including "as needed") in a dosage, or in conjunction with
23other psychotropic medications to a nursing home resident or to
24a resident of a facility licensed under the ID/DD Community
25Care Act or the MC/DD Act, may constitute a chemical restraint
26or an "unnecessary drug" as defined by the Nursing Home Care

 

 

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1Act or Titles XVIII and XIX of the Social Security Act and the
2implementing rules and regulations. The Department shall
3require prior approval for any such medication prescribed for a
4nursing home resident or to a resident of a facility licensed
5under the ID/DD Community Care Act or the MC/DD Act, that
6appears to be a chemical restraint or an unnecessary drug. The
7Department shall consult with the Department of Human Services
8Division of Mental Health in developing a protocol and criteria
9for deciding whether to grant such prior approval.
10    (g) The Department may by rule provide for reimbursement of
11the dispensing of a 90-day supply of a generic or brand name,
12non-narcotic maintenance medication in circumstances where it
13is cost effective.
14    (g-5) On and after July 1, 2012, the Department may require
15the dispensing of drugs to nursing home residents be in a 7-day
16supply or other amount less than a 31-day supply. The
17Department shall pay only one dispensing fee per 31-day supply.
18    (h) Effective July 1, 2011, the Department shall
19discontinue coverage of select over-the-counter drugs,
20including analgesics and cough and cold and allergy
21medications.
22    (h-5) On and after July 1, 2012, the Department shall
23impose utilization controls, including, but not limited to,
24prior approval on specialty drugs, oncolytic drugs, drugs for
25the treatment of HIV or AIDS, immunosuppressant drugs, and
26biological products in order to maximize savings on these

 

 

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1drugs. The Department may adjust payment methodologies for
2non-pharmacy billed drugs in order to incentivize the selection
3of lower-cost drugs. For drugs for the treatment of AIDS, the
4Department shall take into consideration the potential for
5non-adherence by certain populations, and shall develop
6protocols with organizations or providers primarily serving
7those with HIV/AIDS, as long as such measures intend to
8maintain cost neutrality with other utilization management
9controls such as prior approval. For hemophilia, the Department
10shall develop a program of utilization review and control which
11may include, in the discretion of the Department, prior
12approvals. The Department may impose special standards on
13providers that dispense blood factors which shall include, in
14the discretion of the Department, staff training and education;
15patient outreach and education; case management; in-home
16patient assessments; assay management; maintenance of stock;
17emergency dispensing timeframes; data collection and
18reporting; dispensing of supplies related to blood factor
19infusions; cold chain management and packaging practices; care
20coordination; product recalls; and emergency clinical
21consultation. The Department may require patients to receive a
22comprehensive examination annually at an appropriate provider
23in order to be eligible to continue to receive blood factor.
24    (i) On and after July 1, 2012, the Department shall reduce
25any rate of reimbursement for services or other payments or
26alter any methodologies authorized by this Code to reduce any

 

 

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1rate of reimbursement for services or other payments in
2accordance with Section 5-5e.
3    (j) On and after July 1, 2012, the Department shall impose
4limitations on prescription drugs such that the Department
5shall not provide reimbursement for more than 4 prescriptions,
6including 3 brand name prescriptions, for distinct drugs in a
730-day period, unless prior approval is received for all
8prescriptions in excess of the 4-prescription limit. Drugs in
9the following therapeutic classes shall not be subject to prior
10approval as a result of the 4-prescription limit:
11immunosuppressant drugs, oncolytic drugs, anti-retroviral
12drugs, and, on or after July 1, 2014, antipsychotic drugs. On
13or after July 1, 2014, the Department may exempt children with
14complex medical needs enrolled in a care coordination entity
15contracted with the Department to solely coordinate care for
16such children, if the Department determines that the entity has
17a comprehensive drug reconciliation program.
18    (k) No medication therapy management program implemented
19by the Department shall be contrary to the provisions of the
20Pharmacy Practice Act.
21    (l) Any provider enrolled with the Department that bills
22the Department for outpatient drugs and is eligible to enroll
23in the federal Drug Pricing Program under Section 340B of the
24federal Public Health Services Act shall enroll in that
25program. No entity participating in the federal Drug Pricing
26Program under Section 340B of the federal Public Health

 

 

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1Services Act may exclude Medicaid from their participation in
2that program, although the Department may exclude entities
3defined in Section 1905(l)(2)(B) of the Social Security Act
4from this requirement.
5(Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14;
699-180, eff. 7-29-15.)
 
7    (305 ILCS 5/5-36)
8    Sec. 5-36. Pharmacy benefits.
9    (a)(1) The Department may enter into a contract with a
10third party on a fee-for-service reimbursement model for the
11purpose of administering pharmacy benefits as provided in this
12Section for members not enrolled in a Medicaid managed care
13organization; however, these services shall be approved by the
14Department. The Department shall ensure coordination of care
15between the third-party administrator and managed care
16organizations as a consideration in any contracts established
17in accordance with this Section. Any managed care techniques,
18principles, or administration of benefits utilized in
19accordance with this subsection shall comply with State law.
20    (2) The following shall apply to contracts between entities
21contracting relating to the Department's third-party
22administrators and pharmacies:
23        (A) the Department shall approve any contract between a
24    third-party administrator and a pharmacy;
25        (B) the Department's third-party administrator shall

 

 

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1    not change the terms of a contract between a third-party
2    administrator and a pharmacy without written approval by
3    the Department; and
4        (C) the Department's third-party administrator shall
5    not create, modify, implement, or indirectly establish any
6    fee on a pharmacy, pharmacist, or a recipient of medical
7    assistance without written approval by the Department.
8    (b) The provisions of this Section shall not apply to
9outpatient pharmacy services provided by a health care facility
10registered as a covered entity pursuant to 42 U.S.C. 256b or
11any pharmacy owned by or contracted with the covered entity. A
12Medicaid managed care organization shall, either directly or
13through a pharmacy benefit manager, administer and reimburse
14outpatient pharmacy claims submitted by a health care facility
15registered as a covered entity pursuant to 42 U.S.C. 256b, its
16owned pharmacies, and contracted pharmacies in accordance with
17the contractual agreements the Medicaid managed care
18organization or its pharmacy benefit manager has with such
19facilities and pharmacies. Any pharmacy benefit manager that
20contracts with a Medicaid managed care organization to
21administer and reimburse pharmacy claims as provided in this
22Section must be registered with the Director of Insurance in
23accordance with Section 513b2 of the Illinois Insurance Code.
24    (c) On at least an annual basis, the Director of the
25Department of Healthcare and Family Services shall submit a
26report beginning no later than one year after January 1, 2020

 

 

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1(the effective date of Public Act 101-452) this amendatory Act
2of the 101st General Assembly that provides an update on any
3contract, contract issues, formulary, dispensing fees, and
4maximum allowable cost concerns regarding a third-party
5administrator and managed care. The requirement for reporting
6to the General Assembly shall be satisfied by filing copies of
7the report with the Speaker, the Minority Leader, and the Clerk
8of the House of Representatives and with the President, the
9Minority Leader, and the Secretary of the Senate. The
10Department shall take care that no proprietary information is
11included in the report required under this Section.
12    (d) A pharmacy benefit manager shall notify the Department
13in writing of any activity, policy, or practice of the pharmacy
14benefit manager that directly or indirectly presents a conflict
15of interest that interferes with the discharge of the pharmacy
16benefit manager's duty to a managed care organization to
17exercise its contractual duties. "Conflict of interest" shall
18be defined by rule by the Department.
19    (e) A pharmacy benefit manager shall, upon request,
20disclose to the Department the following information:
21        (1) whether the pharmacy benefit manager has a
22    contract, agreement, or other arrangement with a
23    pharmaceutical manufacturer to exclusively dispense or
24    provide a drug to a managed care organization's enrollees,
25    and the aggregate amounts of consideration of economic
26    benefits collected or received pursuant to that

 

 

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1    arrangement;
2        (2) the percentage of claims payments made by the
3    pharmacy benefit manager to pharmacies owned, managed, or
4    controlled by the pharmacy benefit manager or any of the
5    pharmacy benefit manager's management companies, parent
6    companies, subsidiary companies, or jointly held
7    companies;
8        (3) the aggregate amount of the fees or assessments
9    imposed on, or collected from, pharmacy providers; and
10        (4) the average annualized percentage of revenue
11    collected by the pharmacy benefit manager as a result of
12    each contract it has executed with a managed care
13    organization contracted by the Department to provide
14    medical assistance benefits which is not paid by the
15    pharmacy benefit manager to pharmacy providers and
16    pharmaceutical manufacturers or labelers or in order to
17    perform administrative functions pursuant to its contracts
18    with managed care organizations.
19    (f) The information disclosed under subsection (e) shall
20include all retail, mail order, specialty, and compounded
21prescription products. All information made available to the
22Department under subsection (e) is confidential and not subject
23to disclosure under the Freedom of Information Act. All
24information made available to the Department under subsection
25(e) shall not be reported or distributed in any way that
26compromises its competitive, proprietary, or financial value.

 

 

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1The information shall only be used by the Department to assess
2the contract, agreement, or other arrangements made between a
3pharmacy benefit manager and a pharmacy provider,
4pharmaceutical manufacturer or labeler, managed care
5organization, or other entity, as applicable.
6    (g) A pharmacy benefit manager shall disclose directly in
7writing to a pharmacy provider or pharmacy services
8administrative organization contracting with the pharmacy
9benefit manager of any material change to a contract provision
10that affects the terms of the reimbursement, the process for
11verifying benefits and eligibility, dispute resolution,
12procedures for verifying drugs included on the formulary, and
13contract termination at least 30 days prior to the date of the
14change to the provision. The terms of this subsection shall be
15deemed met if the pharmacy benefit manager posts the
16information on a website, viewable by the public. A pharmacy
17service administration organization shall notify all contract
18pharmacies of any material change, as described in this
19subsection, within 2 days of notification. As used in this
20Section, "pharmacy services administrative organization" means
21an entity operating within the State that contracts with
22independent pharmacies to conduct business on their behalf with
23third-party payers. A pharmacy services administrative
24organization may provide administrative services to pharmacies
25and negotiate and enter into contracts with third-party payers
26or pharmacy benefit managers on behalf of pharmacies.

 

 

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1    (h) A pharmacy benefit manager shall not include the
2following in a contract with a pharmacy provider:
3        (1) a provision prohibiting the provider from
4    informing a patient of a less costly alternative to a
5    prescribed medication; or
6        (2) a provision that prohibits the provider from
7    dispensing a particular amount of a prescribed medication,
8    if the pharmacy benefit manager allows that amount to be
9    dispensed through a pharmacy owned or controlled by the
10    pharmacy benefit manager, unless the prescription drug is
11    subject to restricted distribution by the United States
12    Food and Drug Administration or requires special handling,
13    provider coordination, or patient education that cannot be
14    provided by a retail pharmacy.
15    (i) Nothing in this Section shall be construed to prohibit
16a pharmacy benefit manager from requiring the same
17reimbursement and terms and conditions for a pharmacy provider
18as for a pharmacy owned, controlled, or otherwise associated
19with the pharmacy benefit manager. Reimbursement must not be
20less than the dispensing fees and acquisition costs under the
21fee-for-service program as required under subsection (b) of
22Section 5-5.12.
23    (j) A pharmacy benefit manager shall establish and
24implement a process for the resolution of disputes arising out
25of this Section, which shall be approved by the Department.
26    (k) The Department shall adopt rules establishing

 

 

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1reasonable dispensing fees for fee-for-service payments in
2accordance with guidance or guidelines from the federal Centers
3for Medicare and Medicaid Services.
4(Source: P.A. 101-452, eff. 1-1-20; revised 10-22-19.)
 
5    Section 99. Effective date. This Act takes effect upon
6becoming law.