HB3638ham002 98TH GENERAL ASSEMBLY

Rep. Laura Fine

Filed: 3/5/2014

09800HB3638ham002 LRB098 12067 RPM 56586 a

AMENDMENT TO HOUSE BILL 3638

AMENDMENT NO. ______. Amend House Bill 3638 by replacing everything after the enacting clause with the following:

"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) Notwithstanding any other provision of law, on and after January 1, 2016, a health insurer that provides prescription drug benefits shall utilize and accept the prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits. This Section does not apply to plans for beneficiaries of Medicare or Medicaid.

(b) If a health insurer fails to utilize or accept the prior authorization form, fails to respond within 3 business days after receipt of a completed prior authorization request from a prescribing provider or pharmacist (this timeframe follows the requirements set forth in Section 30 of Chapter 18 of the Medicare Part D Benefit Manual), or fails to respond within 24 hours in the case of an emergency, pursuant to the submission of the prior authorization form developed as described in subsection (c), then the prior authorization request shall be deemed to have been granted and shall be paid for by the health insurer at the health insurer's indicated tier.

(c) On or before July 1, 2015, the Department shall develop a uniform prior authorization form. Notwithstanding any other provision of law, on and after January 1, 2016, if the threshold of a majority of prior authorization requests submitted are not submitted electronically (as determined by rule by the Department), then every prescribing provider and pharmacist may use that uniform prior authorization form to request prior authorization for coverage of prescription drug benefits and every health insurer shall accept that form as sufficient to request prior authorization for prescription drug benefits.

(d) The prior authorization form developed pursuant to subsection (c) shall meet the following criteria:

(1) The form shall not exceed 2 pages.

(2) The form shall be made electronically available by the Department and the health insurer.

(3) The completed form may also be electronically submitted from the prescribing provider or pharmacist to the health insurer.

(4) The Department shall develop the form with input from interested parties from at least one public meeting.

(5) The Department, in development of the standardized form, shall take into consideration the following:

(A) Existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the Department of Healthcare and Family Services.

(B) National standards pertaining to electronic prior authorization.

(e) For the purposes of this Section:

"Pharmacist" has the same meaning as set forth in the Pharmacy Practice Act.

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

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