99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB1359
 
Introduced 2/18/2015, by Sen. Linda Holmes
 
SYNOPSIS AS INTRODUCED:
 

 
215 ILCS 5/356z.23 new

     Amends the Illinois Insurance Code. Provides that a health plan that provides coverage for prescription drugs shall ensure that any required copayment or coinsurance applicable to drugs on a specialty tier does not exceed $100 per month for up to a 30-day supply of any single drug and a beneficiary's annual out-of-pocket expenditures for prescription drugs are limited to no more than fifty percent of the dollar amounts in effect under specified provisions of the federal Patient Protection Affordable Care Act. Provides that a health plan that provides coverage for prescription drugs and uses a tiered formulary shall implement an exceptions process that allows enrollees to request an exception to the tiered cost-sharing structure. Provides that a health plan that provides coverage for prescription drugs shall not place all drugs in a given class on a specialty tier. Effective January 1, 2016.
  


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A BILL FOR
 

  
SB1359LRB099 03770 MLM 23783 b


  
1    AN ACT concerning regulation.
  
 
2    Be it enacted by the People of the State of Illinois,
 
3represented in the General Assembly:
  
 
 
4    Section 5. The Illinois Insurance Code is amended  by adding 
5Section 356z.23 as follows:
 
6    (215 ILCS 5/356z.23 new)
7    Sec. 356z.23. Specialty tier prescription coverage.
8    (a)   As used in this Section:
9        "Coinsurance" means a cost-sharing amount set as a 
10    percentage of the total cost of a drug.
11        "Copayment" means a cost-sharing amount set as a dollar 
12    value.
13        "Non-preferred drug" means a drug in a tier designed 
14    for certain drugs deemed non-preferred and therefore 
15    subject to higher cost-sharing amounts than preferred 
16    drugs.
17        "Preferred drug" means a drug in a tier designed for 
18    certain drugs deemed preferred and therefore subject to 
19    lower cost-sharing amounts than non-preferred drugs.
20        "Specialty tier" means a tier of cost sharing that 
21    imposes cost-sharing obligations that exceed that amount 
22    for non-preferred and preferred drugs.
23        "Tiered formulary" means a formulary that provides 
 
 
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1    coverage for prescription drugs as part of a health plan 
2    for which cost sharing, deductibles, or coinsurance 
3    obligations are determined by category or tier of 
4    prescription drugs and includes at least 2 different tiers.
5    (b)   A health plan that provides coverage for prescription 
6drugs shall ensure that:
7        (1)   any required copayment or coinsurance applicable 
8    to drugs on a specialty tier does not exceed $100 per month 
9    for up to a 30-day supply of any single drug; this limit 
10    shall be inclusive of any patient out-of-pocket spending, 
11    including payments towards any deductibles, copayments, or 
12    coinsurance; further this limit shall be applicable at any 
13    point in the benefit design, including before and after any 
14    applicable deductible is reached; and
15        (2)   a beneficiary's annual out-of-pocket expenditures 
16    for prescription drugs are limited to no more than 50% of 
17    the dollar amounts in effect under Section 1302(c)(1) of 
18    the federal Affordable Care Act for self-only and family 
19    coverage, respectively.
20    (c)   A health plan that provides coverage for prescription 
21drugs and uses a tiered formulary shall implement an exceptions 
22process that allows enrollees to request an exception to the 
23tiered cost-sharing structure. Under an exception, a 
24non-preferred drug may be covered under the cost sharing 
25applicable for preferred drugs if the prescribing health care 
26provider determines that the preferred drug for treatment of 
 
 
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1the same condition either would not be as effective for the 
2individual, would have adverse effects for the individual, or 
3both. If an enrollee is denied a cost-sharing exception, the 
4denial shall be considered an adverse event and shall be 
5subject to the health plan's internal review process.
6    (d)   A health plan that provides coverage for prescription 
7drugs shall not place all drugs in a given class on a specialty 
8tier.
9    (e)   Nothing in this Section shall be construed to require a 
10health plan to:
11        (1)   provide coverage for any additional drugs not 
12    otherwise required by law;
13        (2)   implement specific utilization management 
14    techniques, such as prior authorization or step therapy; or
15        (3)   cease utilization of tiered cost-sharing 
16    structures, including those strategies used to incentivize 
17    use of preventive services, disease management, and 
18    low-cost treatment options.
19    (f)   Nothing in this Section shall be construed to require a 
20pharmacist to substitute a drug without the consent of the 
21prescribing physician.
22    (g)   The Director shall adopt rules outlining the 
23enforcement processes for this Section. 
  
 
24    Section 99. Effective date. This Act takes effect January 
251, 2016.