SB1465 EngrossedLRB099 07911 KTG 28051 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 
5adding Section 5-5.12b as follows:
 
6    (305 ILCS 5/5-5.12b  new)
7    Sec. 5-5.12b. Interferon-free therapy; prior approval.
8    (a)

Prior approval by the Department to administer to a 
9recipient of medical assistance any interferon-free therapy 
10for the treatment of the hepatitis C virus shall be limited to 
11the following criteria:
12        (1) The recipient must be 18 years of age.
13        (2) The recipient must have a diagnosis of chronic 
14    hepatitis C infection, genotype  1, 2, 3, or 4, confirmed by 
15    stage 2 fibrosis.
16        (3) The recipient may not have been previously denied a 
17    prescription for any interferon-free therapy for the 
18    treatment of the hepatitis C virus.
19        (4) The recipient may not have end-stage renal disease 
20    requiring dialysis.
21        (5) The recipient must have sufficient kidney  function 
22    as defined by the Department by rule.
23        (6) The recipient may not have evidence of a known and 
 
 
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1    incurable disease, with a life expectancy of less than 12 
2    months.
3        (7) The recipient may not be receiving hospice care.
4        (8) The recipient may not be taking another treatment 
5    that is harmful to take in combination with any 
6    interferon-free therapy for the treatment of the hepatitis 
7    C virus.
8        (9) The recipient may not have abused a controlled 
9    substance within the past 6 months.
10        (10) The recipient must take a drug test no more than 
11    15 days prior to submission of the prior approval request.
12    (b) The Department may not use the following criteria as a 
13basis for requiring prior approval to administer to a recipient 
14of medical assistance any interferon-free therapy for the 
15treatment of the hepatitis C virus:
16        (1) The fact that the recipient or any female partner 
17    of the recipient is pregnant.
18        (2) The recipient's mental capacity or any 
19    determination related to the recipient's ability to make 
20    appropriate decisions about the interferon-free therapy 
21    treatment or to comply with related instructions.
22        (3) Any evidence or known diagnosis of malignancy of 
23    any body organ.
24        (4) The fact that the recipient is receiving or has 
25    received chemotherapy or radiation therapy.
26        (5) The fact that the recipient was previously 
 
 
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1    administered an interferon-free therapy for the treatment 
2    of the hepatitis C virus.
3    (c) A prescriber of any interferon-free therapy for the 
4treatment of the hepatitis C virus to a recipient of medical 
5assistance shall be one of the following:
6        (1) A gastroenterologist or physician practicing in a 
7    relevant sub-specialty.
8        (2) An infectious disease specialist.
9        (3) Any physician licensed to practice medicine in all 
10    its branches with a current license who has received a 
11    written consultation report from a board-certified 
12    gastroenterologist or specialist in a relevant 
13    sub-specialty or from an infectious disease specialist. A 
14    formal request for prior approval to administer to a 
15    medical assistance recipient any interferon-free therapy 
16    for the treatment of the hepatitis C virus shall not be 
17    submitted to the Department without a written consultation 
18    report as provided in this paragraph.
19    (d) The prescriber must submit lab results to the 
20Department before the treatment begins, at the end of therapy, 
21and 12 weeks after the treatment.
22    (e) The Department shall establish an appeals process for 
23recipients who either fail to meet the criteria established in 
24subsection (a) but who demonstrate a reasonable consideration 
25for continuing treatment, or who received a positive drug test 
26within 15 days of the submission of the prior approval request. 
 
 
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1The Department shall review cases involving recipients who 
2received a positive drug test and who have documentation of a 
3drug interaction that would indicate a positive reading from a 
4urine test or other drug test.
5    (f) The Department shall pay managed care entities  a 
6monthly non-capitated rate for any interferon-free therapy for 
7the treatment of the hepatitis C virus that is prescribed to a 
8recipient of medical assistance. The Department may consider  
9the fee-for-service cost of the prescription, the cost 
10differential of alternative treatments, and the utilization of 
11the drug being prescribed in the development of that rate. 
 
 
12    Section 99. Effective date. This Act takes effect upon 
13becoming law.