093_HB2449ham001

 










                                     LRB093 03277 DRJ 13716 a

 1                    AMENDMENT TO HOUSE BILL 2449

 2        AMENDMENT NO.     .  Amend House Bill 2449  by  replacing
 3    everything after the enacting clause with the following:

 4        "Section  1.  Short  title.  This Act may be cited as the
 5    Mental Health Drug Open Access Authorization Act.

 6        Section 5.  Legislative findings; purpose.
 7        (a)  The General Assembly finds as follows:
 8             (1)  Recipients  of  medical  assistance  under  the
 9        Illinois Public Aid  Code  are  often  the  State's  most
10        disadvantaged   citizens,   burdened   with   significant
11        medical,  financial,  and  social needs. Those recipients
12        benefit from an integrated approach to health  care  with
13        open   and   continuous  access  to  physician-prescribed
14        medications.
15             (2)  Mental  health  patients,  including,  but  not
16        limited to, patients with severe mental illnesses such as
17        schizophrenia,   bipolar    disorder    (manic-depressive
18        illness),  or  depression,  require individually tailored
19        treatments determined by an appropriately trained  health
20        care provider.
21             (3)  Medications  for  mental  illness  are  not the
22        same; medications can vary greatly  in  effectiveness  in
 
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 1        treating  specific symptoms or disorders or in their side
 2        effects. Patient needs vary greatly, and not all patients
 3        respond in the same way to a given treatment.
 4             (4)  There is ample evidence  that  new  medications
 5        offer  therapeutic advantages over older medications when
 6        used within evidence-based clinical practice.
 7             (5)  The  determination  of  the  most   appropriate
 8        medication for a particular patient with a mental illness
 9        should  be  made  on  the basis of patient acceptability,
10        prior individual drug  response,  individual  side-effect
11        profile, and concomitant pharmacotherapies; and, finally,
12        where   multiple   agents   are   equally  documented  as
13        clinically effective, the final evaluation will be price.
14             (6)  As a member of the  direct  caregiver  team,  a
15        patient's physician should determine the most appropriate
16        treatment  that  falls within the scope of evidence-based
17        clinical practice.  As a member of the  direct  caregiver
18        team,  a patient's pharmacist should apply the principles
19        of pharmaceutical care to ensure patient safety  relative
20        to  potential  drug-drug, drug-food, and drug-preexisting
21        medical abnormality interactions.
22        (b)  The purpose of this Act is to ensure that recipients
23    of medical assistance under the Illinois Public Aid Code, and
24    other similarly situated patients,  who  need  treatment  for
25    mental  illness  have  open  and  continuous  access  to  the
26    medications   deemed  appropriate  by  their  physicians  and
27    supported by evidence-based clinical practice.

28        Section 10.  Definitions. In this Act:
29        "Cross-indication" means  that  a  drug  is  used  for  a
30    purpose  generally  held  to  be reasonable, appropriate, and
31    within the scope of evidence-based clinical practice  as  set
32    forth in peer-reviewed literature (not case reports).
33        "Department" means the following:
 
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 1             (1)  In  the case of the Children's Health Insurance
 2        Program under the Children's Health Insurance Program Act
 3        or the  medial  assistance  program  under  the  Illinois
 4        Public Aid Code: the Department of Public Aid.
 5             (2)  In  the  case  of the program of pharmaceutical
 6        assistance under the Senior Citizens and Disabled Persons
 7        Property Tax Relief and  Pharmaceutical  Assistance  Act:
 8        the Department of Revenue.
 9             (3)  In  the  case  of  any other State prescription
10        drug  assistance   program:   the   State   agency   that
11        administers that program.
12        "Mental illness" has the meaning ascribed to that term in
13    the  most  recent  edition  of the Diagnostic and Statistical
14    Manual  of  Mental  Disorders,  published  by  the   American
15    Psychiatric Association.
16        "Prior  authorization"  means  a  procedure  by which the
17    prescriber or dispenser  of  a  drug  must  verify  with  the
18    Department or its contractor that the proposed medical use of
19    that  drug  for  a  patient  meets predetermined criteria for
20    coverage under a program described in Section 15.

21        Section 15.  Affected programs. This Act applies  to  the
22    following programs:
23             (1)  The  Children's  Health Insurance Program under
24        the Children's Health Insurance Program Act.
25             (2)  The medial assistance program under  Article  V
26        of  the  Illinois  Public  Aid  Code,  as well as medical
27        assistance provided to recipients of  General  Assistance
28        under Article VI of that Code.
29             (3)  The  program of pharmaceutical assistance under
30        the Senior Citizens and  Disabled  Persons  Property  Tax
31        Relief and Pharmaceutical Assistance Act.
32             (4)  Any  other  State  prescription drug assistance
33        program.
 
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 1        Section 20. Prior authorization of  mental  health  drugs
 2    prohibited.
 3        (a)  The  Department  may not use or require the use of a
 4    prior  authorization  procedure  in   connection   with   the
 5    dispensing  of  a prescription drug, or reimbursement for the
 6    dispensing of a drug, that  meets  either  of  the  following
 7    criteria:
 8             (1)  According  to  the  most recent version of AHFS
 9        Drug Information, published by the  American  Society  of
10        Health-System   Pharmacists,   or  the  Physician's  Desk
11        Reference, the drug is:
12                  (A)  classified     as     an     anti-anxiety,
13             antidepressant,  or  antipsychotic  central  nervous
14             system drug; or
15                  (B)  cross-indicated  for  a  central   nervous
16             system drug classification.
17             (2)  The  drug  is  prescribed  for the treatment of
18        mental illness.
19        (b)  Nothing   in   this    Section    precludes    prior
20    authorization   requirements   for   dosages   of  prescribed
21    medications that exceed the maximum dosage established by the
22    federal Food and Drug Administration  where  clinical  safety
23    and efficacy have been established.
24        (c)  Notwithstanding   subdivision   (a)(1)(B)   of  this
25    Section, even though a cross-indicated use is not included in
26    the federal Food and  Drug  Administration's  approved  label
27    indications  for the drug, dosages may not exceed the maximum
28    dosage established by the Food and Drug Administration  where
29    clinical safety and efficacy have been established.
30        (d)  In    compliance    with    Health    Care   Finance
31    Administration guidelines, a functional Drug Use Review (DUR)
32    activity  shall  review  clinical  outcomes  and,  based   on
33    evidence-based clinical practices, intervene where clinically
34    appropriate  to  ensure the health and safety of the patients
 
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 1    receiving  health  benefits  coverage  under  the  Children's
 2    Health  Insurance  Program  Act,  medical  assistance   under
 3    Article   V   or   VI   of  the  Illinois  Public  Aid  Code,
 4    pharmaceutical  assistance  under  the  Senior  Citizens  and
 5    Disabled  Persons  Property  Tax  Relief  and  Pharmaceutical
 6    Assistance  Act,  or   benefits   under   any   other   State
 7    prescription drug assistance program.

 8        Section  90.  The Children's Health Insurance Program Act
 9    is amended by adding Section 27 as follows:

10        (215 ILCS 106/27 new)
11        Sec. 27.  Prior authorization  of  mental  health  drugs;
12    other restrictions.
13        (a)  Health   benefits   coverage  provided  to  eligible
14    children under this Act is subject to the Mental Health  Drug
15    Open  Access  Authorization Act, except where the dosage of a
16    prescribed drug exceeds the maximum dosage established by the
17    federal  Food  and  Drug  Administration  where  safety   and
18    clinical efficacy have been established.
19        (b)  Nothing  in  this  Section  shall  be  construed  to
20    prohibit the Department from implementing restrictions, other
21    than  prior  authorization requirements, as necessary for the
22    purpose of ensuring the appropriate  use  of  medications  by
23    program  beneficiaries. Such restrictions include limitations
24    on quantity, prescribing protocols and guidelines, and  other
25    restrictions that are supported by evidence-based medicine.

26        Section  93.  The  Illinois Public Aid Code is amended by
27    changing Sections 5-5.12 and 6-11 as follows:

28        (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
29        Sec. 5-5.12.  Pharmacy payments.
30        (a)  Every  request   submitted   by   a   pharmacy   for
 
                            -6-      LRB093 03277 DRJ 13716 a
 1    reimbursement  under  this  Article  for  prescription  drugs
 2    provided  to  a  recipient  of  aid  under this Article shall
 3    include  the  name  of  the  prescriber  or   an   acceptable
 4    identification number as established by the Department.
 5        (b)  Pharmacies  providing  prescription drugs under this
 6    Article shall be reimbursed at a rate which shall  include  a
 7    professional  dispensing  fee  as  determined by the Illinois
 8    Department,  plus  the  current  acquisition  cost   of   the
 9    prescription  drug  dispensed.  The Illinois Department shall
10    update its  information  on  the  acquisition  costs  of  all
11    prescription  drugs  no  less  frequently than every 30 days.
12    However,  the  Illinois  Department  may  set  the  rate   of
13    reimbursement  for  the  acquisition  cost,  by  rule,  at  a
14    percentage of the current average wholesale acquisition cost.
15        (c)  Reimbursement  under  this  Article for prescription
16    drugs shall be limited  to  reimbursement  for  4  brand-name
17    prescription  drugs  per  patient per month.  This subsection
18    applies only if (i) the brand-name drug  was  not  prescribed
19    for  an  acute  or urgent condition, (ii) the brand-name drug
20    was  not  prescribed  for  Alzheimer's  disease,   arthritis,
21    diabetes, HIV/AIDS, a mental health condition, or respiratory
22    disease,  and  (iii)  a  therapeutically  equivalent  generic
23    medication  has  been  approved  by the federal Food and Drug
24    Administration.
25        (d)  The Department shall  not  impose  requirements  for
26    prior   approval   based   on   a  preferred  drug  list  for
27    anti-retroviral or any atypical antipsychotics,  conventional
28    antipsychotics,  or anticonvulsants used for the treatment of
29    serious mental illnesses until 30 days after it has conducted
30    a study of the impact of such requirements  on  patient  care
31    and  submitted  a  report  to  the  Speaker  of  the House of
32    Representatives and the President of the Senate.  In the case
33    of a conflict between this subsection and the  Mental  Health
34    Drug  Open  Access  Authorization Act, the Mental Health Drug
 
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 1    Open Access Authorization  Act  controls,  except  where  the
 2    dosage  of  a  prescribed  drug  exceeds  the  maximum dosage
 3    established by the federal Food and Drug Administration where
 4    safety and clinical efficacy have been  established.  Nothing
 5    in  the  changes  made  by  this  amendatory  Act of the 93rd
 6    General  Assembly  shall  be  construed   to   prohibit   the
 7    Department  from  implementing restrictions, other than prior
 8    authorization requirements, as necessary for the  purpose  of
 9    ensuring  the appropriate use of medications by recipients of
10    medical assistance  under  this  Article.  Such  restrictions
11    include  limitations  on  quantity, prescribing protocols and
12    guidelines, and other  restrictions  that  are  supported  by
13    evidence-based medicine.
14    (Source:  P.A.  92-597,  eff.  6-28-02; 92-825, eff. 8-21-02;
15    revised 9-19-02.)

16        (305 ILCS 5/6-11) (from Ch. 23, par. 6-11)
17        Sec. 6-11.  State funded General Assistance.
18        (a)  Effective July 1, 1992,  all  State  funded  General
19    Assistance  and related medical benefits shall be governed by
20    this Section.  Other parts of this Code or other laws related
21    to General Assistance shall remain in effect  to  the  extent
22    they do not conflict with the provisions of this Section.  If
23    any  other  part  of  this  Code  or other laws of this State
24    conflict with the provisions of this Section, the  provisions
25    of this Section shall control.
26        (b)  State  funded  General Assistance shall consist of 2
27    separate programs.  One program shall be for adults  with  no
28    children and shall be known as State Transitional Assistance.
29    The other program shall be for families with children and for
30    pregnant  women  and  shall  be  known  as  State  Family and
31    Children Assistance.
32        (c) (1)  To be eligible for State Transitional Assistance
33    on or after July 1, 1992, an individual  must  be  ineligible
 
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 1    for  assistance under any other Article of this Code, must be
 2    determined  chronically  needy,  and  must  be  one  of   the
 3    following:
 4             (A)  age 18 or over or
 5             (B)  married and living with a spouse, regardless of
 6        age.
 7        (2)  The  Illinois  Department  or the local governmental
 8    unit shall  determine  whether  individuals  are  chronically
 9    needy as follows:
10             (A)  Individuals  who  have applied for Supplemental
11        Security Income (SSI) and  are  awaiting  a  decision  on
12        eligibility  for  SSI  who are determined disabled by the
13        Illinois Department  using  the  SSI  standard  shall  be
14        considered  chronically  needy,  except  that individuals
15        whose disability is based solely on substance  addictions
16        (drug  abuse  and  alcoholism) and whose disability would
17        cease were their addictions to end shall be eligible only
18        for medical assistance and shall not be eligible for cash
19        assistance  under  the  State   Transitional   Assistance
20        program.
21             (B)  If  an  individual has been denied SSI due to a
22        finding of "not disabled" (either at  the  Administrative
23        Law  Judge  level  or  above, or at a lower level if that
24        determination was not appealed), the Illinois  Department
25        shall  adopt that finding and the individual shall not be
26        eligible for State Transitional Assistance or any related
27        medical  benefits.   Such  an  individual  may   not   be
28        determined  disabled  by  the  Illinois  Department for a
29        period of 12 months, unless  the  individual  shows  that
30        there has been a substantial change in his or her medical
31        condition  or that there has been a substantial change in
32        other factors, such as age or work experience, that might
33        change the determination of disability.
34             (C)  The Illinois Department, by rule,  may  specify
 
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 1        other  categories  of  individuals  as chronically needy;
 2        nothing in this Section,  however,  shall  be  deemed  to
 3        require the inclusion of any specific category other than
 4        as specified in paragraphs (A) and (B).
 5        (3)  For  individuals  in  State Transitional Assistance,
 6    medical assistance shall be provided in an amount and  nature
 7    determined  by the Illinois Department of Public Aid by rule.
 8    The amount and nature of medical assistance provided need not
 9    be  the  same  as  that  provided  under  paragraph  (4)   of
10    subsection (d) of this Section, and nothing in this paragraph
11    (3)  shall  be  construed  to  require  the  coverage  of any
12    particular medical  service.  In  addition,  the  amount  and
13    nature  of  medical  assistance provided may be different for
14    different categories of  individuals  determined  chronically
15    needy.
16        (4)  The  Illinois  Department  shall determine, by rule,
17    those assistance recipients under Article  VI  who  shall  be
18    subject   to  employment,  training,  or  education  programs
19    including Earnfare, the content of those  programs,  and  the
20    penalties for failure to cooperate in those programs.
21        (5)  The  Illinois  Department  shall, by rule, establish
22    further eligibility requirements, including but  not  limited
23    to residence, need, and the level of payments.
24        (d) (1)  To  be  eligible  for  State Family and Children
25    Assistance, a family unit must be ineligible  for  assistance
26    under any other Article of this Code and must contain a child
27    who is:
28             (A)  under age 18 or
29             (B)  age  18  and a full-time student in a secondary
30        school or the equivalent level of vocational or technical
31        training, and who may reasonably be expected to  complete
32        the program before reaching age 19.
33        Those  children  shall  be  eligible for State Family and
34    Children Assistance.
 
                            -10-     LRB093 03277 DRJ 13716 a
 1        (2)  The natural or adoptive parents of the child  living
 2    in  the  same  household may be eligible for State Family and
 3    Children Assistance.
 4        (3)  A pregnant woman whose pregnancy has  been  verified
 5    shall be eligible for income maintenance assistance under the
 6    State Family and Children Assistance program.
 7        (4)  The amount and nature of medical assistance provided
 8    under  the State Family and Children Assistance program shall
 9    be determined by the Illinois Department  of  Public  Aid  by
10    rule.  The  amount  and nature of medical assistance provided
11    need not be the same as that provided under paragraph (3)  of
12    subsection (c) of this Section, and nothing in this paragraph
13    (4)  shall  be  construed  to  require  the  coverage  of any
14    particular medical service.
15        (5)  The Illinois Department shall,  by  rule,  establish
16    further  eligibility  requirements, including but not limited
17    to residence, need, and the level of payments.
18        (d-5)  Medical assistance benefits provided  to  eligible
19    recipients  under  this  Section  are  subject  to the Mental
20    Health Drug Open Access Authorization Act.  Nothing  in  this
21    subsection  shall  be construed to prohibit the Department of
22    Public Aid from implementing restrictions, other  than  prior
23    authorization  requirements,  as necessary for the purpose of
24    ensuring the appropriate use of medications by recipients  of
25    medical  assistance  under  this  Section.  Such restrictions
26    include limitations on quantity,  prescribing  protocols  and
27    guidelines,  and  other  restrictions  that  are supported by
28    evidence-based medicine.
29        (e)  A  local   governmental   unit   that   chooses   to
30    participate  in  a  General  Assistance  program  under  this
31    Section  shall  provide  funding  in  accordance with Section
32    12-21.13 of  this  Act.  Local  governmental  funds  used  to
33    qualify  for  State  funding may only be expended for clients
34    eligible for assistance under this Section 6-11  and  related
 
                            -11-     LRB093 03277 DRJ 13716 a
 1    administrative expenses.
 2        (f)  In  order  to  qualify  for State funding under this
 3    Section, a local governmental unit shall be  subject  to  the
 4    supervision  and  the  rules  and regulations of the Illinois
 5    Department.
 6        (g)  Notwithstanding any other provision  in  this  Code,
 7    the  Illinois  Department  is  authorized  to  reduce payment
 8    levels used to determine cash grants provided  to  recipients
 9    of  State Transitional Assistance at any time within a Fiscal
10    Year  in  order  to  ensure  that  cash  benefits  for  State
11    Transitional   Assistance   do   not   exceed   the   amounts
12    appropriated for those  cash  benefits.  Changes  in  payment
13    levels  may  be  accomplished by emergency rule under Section
14    5-45 of the Illinois  Administrative  Procedure  Act,  except
15    that the limitation on the number of emergency rules that may
16    be  adopted  in  a  24-month  period  shall not apply and the
17    provisions of  Sections  5-115  and  5-125  of  the  Illinois
18    Administrative Procedure Act shall not apply.  This provision
19    shall  also  be applicable to any reduction in payment levels
20    made upon implementation of this amendatory Act of 1995.
21    (Source: P.A. 92-111, eff. 1-1-02.)

22        Section 95.  The Senior  Citizens  and  Disabled  Persons
23    Property  Tax  Relief  and  Pharmaceutical  Assistance Act is
24    amended by changing Section 4 as follows:

25        (320 ILCS 25/4) (from Ch. 67 1/2, par. 404)
26        Sec. 4.  Amount of Grant.
27        (a)  In general.  Any individual 65 years or older or any
28    individual who will become 65 years old during  the  calendar
29    year  in  which a claim is filed, and any surviving spouse of
30    such a claimant, who at the time of  death  received  or  was
31    entitled  to  receive a grant pursuant to this Section, which
32    surviving spouse will become 65 years of age  within  the  24
 
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 1    months  immediately  following the death of such claimant and
 2    which surviving spouse but for his or her  age  is  otherwise
 3    qualified  to  receive  a grant pursuant to this Section, and
 4    any disabled person whose annual  household  income  is  less
 5    than $14,000 for grant years before the 1998 grant year, less
 6    than $16,000 for the 1998 and 1999 grant years, and less than
 7    (i)  $21,218  for  a  household  containing  one person, (ii)
 8    $28,480 for  a  household  containing  2  persons,  or  (iii)
 9    $35,740  for a household containing 3 or more persons for the
10    2000 grant year and thereafter and whose household is  liable
11    for  payment  of  property  taxes  accrued  or  has paid rent
12    constituting property taxes accrued and is domiciled in  this
13    State  at  the  time  he  or  she  files  his or her claim is
14    entitled to claim a grant under this  Act.  With  respect  to
15    claims  filed  by  individuals  who  will become 65 years old
16    during the calendar year in  which  a  claim  is  filed,  the
17    amount of any grant to which that household is entitled shall
18    be  an  amount  equal  to  1/12  of  the  amount to which the
19    claimant would otherwise be  entitled  as  provided  in  this
20    Section,  multiplied  by  the  number  of months in which the
21    claimant was 65 in the calendar year in which  the  claim  is
22    filed.
23        (b)  Limitation.    Except   as   otherwise  provided  in
24    subsections (a) and (f) of this Section, the  maximum  amount
25    of  grant which a claimant is entitled to claim is the amount
26    by which the  property  taxes  accrued  which  were  paid  or
27    payable   during   the   last  preceding  tax  year  or  rent
28    constituting  property  taxes  accrued  upon  the  claimant's
29    residence for the last preceding taxable year exceeds 3  1/2%
30    of  the  claimant's  household income for that year but in no
31    event is the grant to exceed (i) $700 less 4.5% of  household
32    income  for  that  year  for those with a household income of
33    $14,000 or less or (ii) $70 if household income for that year
34    is more than $14,000.
 
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 1        (c)  Public aid recipients.  If household income  in  one
 2    or  more  months  during  a  year includes cash assistance in
 3    excess of $55 per month from the Department of Public Aid  or
 4    the  Department of Human Services (acting as successor to the
 5    Department of  Public  Aid  under  the  Department  of  Human
 6    Services  Act) which was determined under regulations of that
 7    Department on a measure of need that  included  an  allowance
 8    for  actual  rent  or property taxes paid by the recipient of
 9    that assistance, the amount of grant to which that  household
10    is  entitled, except as otherwise provided in subsection (a),
11    shall be the product of (1) the maximum  amount  computed  as
12    specified in subsection (b) of this Section and (2) the ratio
13    of  the  number  of  months in which household income did not
14    include such cash assistance over $55 to the  number  twelve.
15    If household income did not include such cash assistance over
16    $55  for  any months during the year, the amount of the grant
17    to which the household  is  entitled  shall  be  the  maximum
18    amount  computed  as  specified  in  subsection  (b)  of this
19    Section.   For  purposes  of  this   paragraph   (c),   "cash
20    assistance"  does  not  include any amount received under the
21    federal Supplemental Security Income (SSI) program.
22        (d)  Joint ownership.  If title to the residence is  held
23    jointly  by the claimant with a person who is not a member of
24    his or her household, the amount of  property  taxes  accrued
25    used  in  computing the amount of grant to which he or she is
26    entitled shall be  the  same  percentage  of  property  taxes
27    accrued  as  is  the  percentage  of  ownership  held  by the
28    claimant in the residence.
29        (e)  More than one residence.  If a claimant has occupied
30    more than one residence in the taxable year, he  or  she  may
31    claim  only  one  residence  for any part of a month.  In the
32    case of property taxes accrued, he or she shall prorate  1/12
33    of  the  total property taxes accrued on his or her residence
34    to each  month  that  he  or  she  owned  and  occupied  that
 
                            -14-     LRB093 03277 DRJ 13716 a
 1    residence;  and,  in  the  case of rent constituting property
 2    taxes accrued, shall prorate each month's  rent  payments  to
 3    the residence actually occupied during that month.
 4        (f)  There   is   hereby   established   a   program   of
 5    pharmaceutical  assistance  to  the  aged  and disabled which
 6    shall be administered by the Department  in  accordance  with
 7    this Act, to consist of payments to authorized pharmacies, on
 8    behalf  of  beneficiaries  of the program, for the reasonable
 9    costs of covered prescription drugs.   Each  beneficiary  who
10    pays  $5  for  an identification card shall pay no additional
11    prescription costs.  Each beneficiary who  pays  $25  for  an
12    identification  card  shall  pay  $3  per  prescription.   In
13    addition,  after  a  beneficiary  receives $2,000 in benefits
14    during a State fiscal year, that beneficiary  shall  also  be
15    charged  20%  of  the  cost  of  each  prescription for which
16    payments are made by the program during the remainder of  the
17    fiscal  year.   To  become a beneficiary under this program a
18    person must: (1) be (i) 65 years of age or older, or (ii) the
19    surviving spouse of such a claimant, who at the time of death
20    received or was entitled to receive benefits pursuant to this
21    subsection, which surviving spouse will become  65  years  of
22    age  within  the 24 months immediately following the death of
23    such claimant and which surviving spouse but for his  or  her
24    age  is  otherwise  qualified to receive benefits pursuant to
25    this subsection, or (iii) disabled, and (2) be  domiciled  in
26    this  State at the time he or she files his or her claim, and
27    (3) have a maximum household income of less than $14,000  for
28    grant years before the 1998 grant year, less than $16,000 for
29    the  1998 and 1999 grant years, and less than (i) $21,218 for
30    a  household  containing  one  person,  (ii)  $28,480  for  a
31    household containing  2  persons,  or  (iii)  $35,740  for  a
32    household  containing  3 more persons for the 2000 grant year
33    and thereafter.  In addition, each eligible person  must  (1)
34    obtain an identification card from the Department, (2) at the
 
                            -15-     LRB093 03277 DRJ 13716 a
 1    time  the card is obtained, sign a statement assigning to the
 2    State of Illinois benefits which  may  be  otherwise  claimed
 3    under  any  private  insurance  plans,  and  (3)  present the
 4    identification card to the dispensing pharmacist.
 5        Whenever a generic equivalent for a covered  prescription
 6    drug  is  available,  the Department shall reimburse only for
 7    the reasonable costs of  the  generic  equivalent,  less  the
 8    co-pay  established  in  this Section, unless (i) the covered
 9    prescription drug contains one or more ingredients defined as
10    a narrow therapeutic index drug at 21 CFR  320.33,  (ii)  the
11    prescriber  indicates  on the face of the prescription "brand
12    medically necessary", and (iii) the prescriber specifies that
13    a substitution  is  not  permitted.   When  issuing  an  oral
14    prescription for covered prescription medication described in
15    item  (i)  of  this paragraph, the prescriber shall stipulate
16    "brand medically necessary" and that a  substitution  is  not
17    permitted.    If   the  covered  prescription  drug  and  its
18    authorizing prescription do  not  meet  the  criteria  listed
19    above,   the   beneficiary   may   purchase  the  non-generic
20    equivalent of the covered prescription  drug  by  paying  the
21    difference  between the generic cost and the non-generic cost
22    plus the beneficiary co-pay.
23        Pharmaceutical assistance benefits provided  to  eligible
24    persons  under this Act are subject to the Mental Health Drug
25    Open Access Authorization Act.  Nothing in the  changes  made
26    by  this amendatory Act of the 93rd General Assembly shall be
27    construed  to  prohibit  the  Department  of   Revenue   from
28    implementing  restrictions,  other  than  prior authorization
29    requirements, as necessary for the purpose  of  ensuring  the
30    appropriate    use    of   medications   by   recipients   of
31    pharmaceutical assistance under this Act.  Such  restrictions
32    include  limitations  on  quantity, prescribing protocols and
33    guidelines, and other  restrictions  that  are  supported  by
34    evidence-based medicine.
 
                            -16-     LRB093 03277 DRJ 13716 a
 1        Any   person   otherwise   eligible   for  pharmaceutical
 2    assistance under this Act whose covered drugs are covered  by
 3    any  public  program for assistance in purchasing any covered
 4    prescription drugs shall be ineligible for  assistance  under
 5    this  Act  to the extent such costs are covered by such other
 6    plan.
 7        The  fee  to  be  charged  by  the  Department  for   the
 8    identification  card  shall  be equal to $5 per coverage year
 9    for persons below the official poverty line as defined by the
10    United States Department of Health and Human Services and $25
11    per coverage year for all other persons.
12        In the event that 2 or more persons are eligible for  any
13    benefit   under  this  Act,  and  are  members  of  the  same
14    household,  (1)  each  such  person  shall  be  entitled   to
15    participate   in   the   pharmaceutical  assistance  program,
16    provided that he or she meets all other requirements  imposed
17    by  this  subsection  and  (2)  each  participating household
18    member contributes the fee required for that  person  by  the
19    preceding   paragraph   for   the  purpose  of  obtaining  an
20    identification card.
21    (Source: P.A. 91-357,  eff.  7-29-99;  91-699,  eff.  1-1-01;
22    92-131,  eff.  7-23-01;  92-519,  eff.  1-1-02;  92-651, eff.
23    7-11-02.)

24        Section 99.  Effective date.  This Act takes effect  upon
25    becoming law.".