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1 | AN ACT concerning regulation.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 5. The Illinois Insurance Code is amended by | |||||||||||||||||||||
5 | adding Sections 356z.61 and 513b7 as follows: | |||||||||||||||||||||
6 | (215 ILCS 5/356z.61 new) | |||||||||||||||||||||
7 | Sec. 356z.61. Patient prescription pricing transparency. | |||||||||||||||||||||
8 | (a) As used in this Section: | |||||||||||||||||||||
9 | "Authorized third party" includes a third party legally | |||||||||||||||||||||
10 | authorized under State or federal law subject to a Health | |||||||||||||||||||||
11 | Insurance Portability and Accountability Act of 1996 business | |||||||||||||||||||||
12 | associate agreement. | |||||||||||||||||||||
13 | "Cost-sharing information" means the amount a covered | |||||||||||||||||||||
14 | individual is required to pay to receive a drug that is covered | |||||||||||||||||||||
15 | under the covered individual's health plan. | |||||||||||||||||||||
16 | "Coverage" means those health care services to which a | |||||||||||||||||||||
17 | covered individual is entitled under the terms of the health | |||||||||||||||||||||
18 | plan. | |||||||||||||||||||||
19 | "Electronic health record" means a digital version of a | |||||||||||||||||||||
20 | patient's paper chart and medical history that makes | |||||||||||||||||||||
21 | information available instantly and securely to authorized | |||||||||||||||||||||
22 | users. | |||||||||||||||||||||
23 | "Electronic prescribing system" means a system that |
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1 | enables prescribers to enter prescription information into a | ||||||
2 | computer prescription device and securely transmit the | ||||||
3 | prescription to pharmacies using a special software program | ||||||
4 | and connectivity to a transmission network. | ||||||
5 | "Prescriber" means a health care provider licensed to | ||||||
6 | prescribe medication or medical devices in this State. | ||||||
7 | "Real-time benefit tool" means an electronic prescription | ||||||
8 | decision support tool that (i) is capable of integrating with | ||||||
9 | prescribers' electronic prescribing and, if feasible, | ||||||
10 | electronic health record systems; and (ii) complies with the | ||||||
11 | technical standards adopted by an American National Standards | ||||||
12 | Institute accredited standards development organization. | ||||||
13 | (b) No later than July 1, 2024, each health plan operating | ||||||
14 | in this State shall, upon request of a covered individual, his | ||||||
15 | or her health care provider, or an authorized third party on | ||||||
16 | his or her behalf, furnish the cost, benefit, and coverage | ||||||
17 | data required under this Section to the covered individual, | ||||||
18 | his or her health care provider, or the third party of his or | ||||||
19 | her choosing and shall ensure that the data is: | ||||||
20 | (1) current no later than one business day after any | ||||||
21 | change is made; | ||||||
22 | (2) provided in real time; and | ||||||
23 | (3) in a format that is easily accessible to the | ||||||
24 | covered individual or, in the case of his or her health | ||||||
25 | care provider, through an electronic health records | ||||||
26 | system. |
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1 | (c) The format of the request shall use established | ||||||
2 | industry content and transport standards published by: | ||||||
3 | (1) a standards developing organization accredited by | ||||||
4 | the American National Standards Institute, including the | ||||||
5 | National Council for Prescription Drug Programs, | ||||||
6 | Accredited Standards Committee X12, and Health Level 7; | ||||||
7 | (2) a relevant federal or state governing body, | ||||||
8 | including the Centers for Medicare & Medicaid Services or | ||||||
9 | the Office of the National Coordinator for Health | ||||||
10 | Information Technology; or | ||||||
11 | (3) another format deemed acceptable to the Department | ||||||
12 | that provides the data described in subsection (a) and | ||||||
13 | with the same timeliness as required by this Section. | ||||||
14 | (d) A facsimile is not an acceptable electronic format | ||||||
15 | under this Section. | ||||||
16 | (e) Upon request, the following data shall be provided for | ||||||
17 | any drug covered under the covered individual's health plan: | ||||||
18 | (1) patient-specific eligibility information; | ||||||
19 | (2) patient-specific prescription cost and benefit | ||||||
20 | data, such as applicable formulary, benefit, coverage and | ||||||
21 | cost-sharing data for the prescribed drug, and clinically | ||||||
22 | appropriate alternatives, when appropriate; | ||||||
23 | (3) patient-specific cost-sharing information that | ||||||
24 | describes variance in cost sharing based on the pharmacy | ||||||
25 | dispensing the prescribed drug or its alternatives, and in | ||||||
26 | relation to the patient's benefit, such as spending |
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1 | related to the out-of-pocket maximum; | ||||||
2 | (4) information regarding lower cost clinically | ||||||
3 | appropriate treatment alternatives; and | ||||||
4 | (5) applicable utilization management requirements. | ||||||
5 | (f) Any health plan shall furnish the data as required | ||||||
6 | whether the request is made using the drug's unique billing | ||||||
7 | code, such as a National Drug Code or Healthcare Common | ||||||
8 | Procedure Coding System code, or descriptive term. A health | ||||||
9 | plan shall not deny or unreasonably delay a request as a method | ||||||
10 | of blocking the required data from being shared based on how | ||||||
11 | the drug was requested. | ||||||
12 | (g) A health plan shall not restrict, prohibit, or | ||||||
13 | otherwise hinder the prescriber from communicating or sharing | ||||||
14 | benefit and coverage information that reflects other choices, | ||||||
15 | such as cash price, lower cost clinically appropriate | ||||||
16 | alternatives, whether or not they are covered under the | ||||||
17 | covered individual's plan and support programs, and the cost | ||||||
18 | available at the patient's pharmacy of choice. | ||||||
19 | (h) A health plan shall not, except as may be required by | ||||||
20 | law, interfere with, prevent, or materially discourage access, | ||||||
21 | exchange, or use of the data as required, which may include | ||||||
22 | charging fees or not responding to a request for such data in a | ||||||
23 | reasonable time frame; nor penalize a health care provider or | ||||||
24 | professional for disclosing such information to a covered | ||||||
25 | individual or legally prescribing, administering, or ordering | ||||||
26 | a clinically appropriate or lower cost alternative. |
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1 | (i) Nothing in this Section shall be construed to limit | ||||||
2 | access to the most up-to-date patient-specific eligibility or | ||||||
3 | patient-specific prescription cost and benefit data by the | ||||||
4 | health plan. | ||||||
5 | (j) Nothing in this Section shall interfere with patient | ||||||
6 | choice and a health care professional's ability to convey the | ||||||
7 | full range of prescription drug cost options to a patient. | ||||||
8 | Health plans shall not restrict a health care professional | ||||||
9 | from communicating prescription cost options to the patient. | ||||||
10 | (k) No real-time benefit tool shall require a patient to | ||||||
11 | use specific plan-preferred drugs or pharmacies. | ||||||
12 | (215 ILCS 5/513b7 new) | ||||||
13 | Sec. 513b7. Patient prescription pricing transparency. | ||||||
14 | (a) No later than July 1, 2024, each pharmacy benefit | ||||||
15 | manager operating in this State shall, upon request of a | ||||||
16 | covered individual, his or her health care provider, or an | ||||||
17 | authorized third party on his or her behalf, furnish the cost, | ||||||
18 | benefit, and coverage data required under this Section to the | ||||||
19 | covered individual, his or her health care provider, or the | ||||||
20 | third party of his or her choosing and shall ensure that the | ||||||
21 | data is: | ||||||
22 | (1) current no later than one business day after any | ||||||
23 | change is made; | ||||||
24 | (2) provided in real time; and | ||||||
25 | (3) in a format that is easily accessible to the |
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1 | covered individual or, in the case of his or her health | ||||||
2 | care provider, through an electronic health records | ||||||
3 | system. | ||||||
4 | (b) The format of the request shall use established | ||||||
5 | industry content and transport standards published by: | ||||||
6 | (1) a standards developing organization accredited by | ||||||
7 | the American National Standards Institute, including the | ||||||
8 | National Council for Prescription Drug Programs, | ||||||
9 | Accredited Standards Committee X12, and Health Level 7; | ||||||
10 | (2) a relevant federal or state governing body, | ||||||
11 | including the Centers for Medicare & Medicaid Services or | ||||||
12 | the Office of the National Coordinator for Health | ||||||
13 | Information Technology; or | ||||||
14 | (3) another format deemed acceptable to the Department | ||||||
15 | that provides the data described in subsection (a) and | ||||||
16 | with the same timeliness as required by this Section. | ||||||
17 | (c) A facsimile is not an acceptable electronic format | ||||||
18 | under this Section. | ||||||
19 | (d) Upon request, the following data shall be provided for | ||||||
20 | any drug covered under the covered individual's health plan: | ||||||
21 | (1) patient-specific eligibility information; | ||||||
22 | (2) patient-specific prescription cost and benefit | ||||||
23 | data, such as applicable formulary, benefit, coverage and | ||||||
24 | cost-sharing data for the prescribed drug, and clinically | ||||||
25 | appropriate alternatives, when appropriate; | ||||||
26 | (3) patient-specific cost-sharing information that |
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1 | describes variance in cost sharing based on the pharmacy | ||||||
2 | dispensing the prescribed drug or its alternatives, and in | ||||||
3 | relation to the patient's benefit, such as spending | ||||||
4 | related to the out-of-pocket maximum; | ||||||
5 | (4) information regarding lower cost clinically | ||||||
6 | appropriate treatment alternatives; and | ||||||
7 | (5) applicable utilization management requirements. | ||||||
8 | (e) A pharmacy benefit manager shall furnish the data as | ||||||
9 | required whether the request is made using the drug's unique | ||||||
10 | billing code, such as a National Drug Code or Healthcare | ||||||
11 | Common Procedure Coding System code, or descriptive term. A | ||||||
12 | pharmacy benefit manager shall not deny or unreasonably delay | ||||||
13 | a request as a method of blocking the required data from being | ||||||
14 | shared based on how the drug was requested. | ||||||
15 | (f) A pharmacy benefit manager shall not restrict, | ||||||
16 | prohibit, or otherwise hinder the prescriber from | ||||||
17 | communicating or sharing benefit and coverage information that | ||||||
18 | reflects other choices, such as cash price, lower cost | ||||||
19 | clinically appropriate alternatives, whether or not they are | ||||||
20 | covered under the covered individual's plan, patient | ||||||
21 | assistance programs, and support programs, and the cost | ||||||
22 | available at the patient's pharmacy of choice. | ||||||
23 | (g) A pharmacy benefit manager shall not, except as may be | ||||||
24 | required by law, interfere with, prevent, or materially | ||||||
25 | discourage access, exchange, or use of the data as required, | ||||||
26 | which may include charging fees or not responding to a request |
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1 | for such data in a reasonable time frame; nor penalize a health | ||||||
2 | care provider or professional for disclosing such information | ||||||
3 | to a covered individual or legally prescribing, administering, | ||||||
4 | or ordering a clinically appropriate or lower cost | ||||||
5 | alternative. | ||||||
6 | (h) Nothing in this Section shall be construed to limit | ||||||
7 | access to the most up-to-date patient-specific eligibility or | ||||||
8 | patient-specific prescription cost and benefit data by the | ||||||
9 | pharmacy benefit manager. | ||||||
10 | (i) Nothing in this Section shall interfere with patient | ||||||
11 | choice and a health care professional's ability to convey the | ||||||
12 | full range of prescription drug cost options to a patient. A | ||||||
13 | pharmacy benefit manager shall not restrict a health care | ||||||
14 | professional from communicating prescription cost options to | ||||||
15 | the patient. | ||||||
16 | (j) No real-time benefit tool shall require a patient to | ||||||
17 | use specific plan-preferred drugs or pharmacies.
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