103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
SB1618

 

Introduced 2/8/2023, by Sen. Julie A. Morrison

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.61 new
215 ILCS 5/513b7 new

    Amends the Illinois Insurance Code. Provides that no later than July 1, 2024, each health plan and pharmacy benefit manager operating in this State shall, upon request of a covered individual, his or her health care provider, or an authorized third party on his or her behalf, furnish specified cost, benefit, and coverage data to the covered individual, his or her health care provider, or the third party of his or her choosing and shall ensure that the data is: (1) current no later than one business day after any change is made; (2) provided in real time; and (3) in a format that is easily accessible to the covered individual or, in the case of his or her health care provider, through an electronic health records system. Provides that the format of the request shall use specified industry content and transport standards. Provides that a facsimile is not an acceptable electronic format. Provides that upon request, specified data shall be provided for any drug covered under the covered individual's health plan. Makes other changes. Defines terms.


LRB103 29540 BMS 55935 b

 

 

A BILL FOR

 

SB1618LRB103 29540 BMS 55935 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
5adding 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
10authorized under State or federal law subject to a Health
11Insurance Portability and Accountability Act of 1996 business
12associate agreement.
13    "Cost-sharing information" means the amount a covered
14individual is required to pay to receive a drug that is covered
15under the covered individual's health plan.
16    "Coverage" means those health care services to which a
17covered individual is entitled under the terms of the health
18plan.
19    "Electronic health record" means a digital version of a
20patient's paper chart and medical history that makes
21information available instantly and securely to authorized
22users.
23    "Electronic prescribing system" means a system that

 

 

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1enables prescribers to enter prescription information into a
2computer prescription device and securely transmit the
3prescription to pharmacies using a special software program
4and connectivity to a transmission network.
5    "Prescriber" means a health care provider licensed to
6prescribe medication or medical devices in this State.
7    "Real-time benefit tool" means an electronic prescription
8decision support tool that (i) is capable of integrating with
9prescribers' electronic prescribing and, if feasible,
10electronic health record systems; and (ii) complies with the
11technical standards adopted by an American National Standards
12Institute accredited standards development organization.
13    (b) No later than July 1, 2024, each health plan operating
14in this State shall, upon request of a covered individual, his
15or her health care provider, or an authorized third party on
16his or her behalf, furnish the cost, benefit, and coverage
17data required under this Section to the covered individual,
18his or her health care provider, or the third party of his or
19her 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
2industry 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
15under this Section.
16    (e) Upon request, the following data shall be provided for
17any 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
6whether the request is made using the drug's unique billing
7code, such as a National Drug Code or Healthcare Common
8Procedure Coding System code, or descriptive term. A health
9plan shall not deny or unreasonably delay a request as a method
10of blocking the required data from being shared based on how
11the drug was requested.
12    (g) A health plan shall not restrict, prohibit, or
13otherwise hinder the prescriber from communicating or sharing
14benefit and coverage information that reflects other choices,
15such as cash price, lower cost clinically appropriate
16alternatives, whether or not they are covered under the
17covered individual's plan and support programs, and the cost
18available at the patient's pharmacy of choice.
19    (h) A health plan shall not, except as may be required by
20law, interfere with, prevent, or materially discourage access,
21exchange, or use of the data as required, which may include
22charging fees or not responding to a request for such data in a
23reasonable time frame; nor penalize a health care provider or
24professional for disclosing such information to a covered
25individual or legally prescribing, administering, or ordering
26a clinically appropriate or lower cost alternative.

 

 

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1    (i) Nothing in this Section shall be construed to limit
2access to the most up-to-date patient-specific eligibility or
3patient-specific prescription cost and benefit data by the
4health plan.
5    (j) Nothing in this Section shall interfere with patient
6choice and a health care professional's ability to convey the
7full range of prescription drug cost options to a patient.
8Health plans shall not restrict a health care professional
9from communicating prescription cost options to the patient.
10    (k) No real-time benefit tool shall require a patient to
11use 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
15manager operating in this State shall, upon request of a
16covered individual, his or her health care provider, or an
17authorized third party on his or her behalf, furnish the cost,
18benefit, and coverage data required under this Section to the
19covered individual, his or her health care provider, or the
20third party of his or her choosing and shall ensure that the
21data 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

 

 

SB1618- 6 -LRB103 29540 BMS 55935 b

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
5industry 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
18under this Section.
19    (d) Upon request, the following data shall be provided for
20any 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
9required whether the request is made using the drug's unique
10billing code, such as a National Drug Code or Healthcare
11Common Procedure Coding System code, or descriptive term. A
12pharmacy benefit manager shall not deny or unreasonably delay
13a request as a method of blocking the required data from being
14shared based on how the drug was requested.
15    (f) A pharmacy benefit manager shall not restrict,
16prohibit, or otherwise hinder the prescriber from
17communicating or sharing benefit and coverage information that
18reflects other choices, such as cash price, lower cost
19clinically appropriate alternatives, whether or not they are
20covered under the covered individual's plan, patient
21assistance programs, and support programs, and the cost
22available at the patient's pharmacy of choice.
23    (g) A pharmacy benefit manager shall not, except as may be
24required by law, interfere with, prevent, or materially
25discourage access, exchange, or use of the data as required,
26which may include charging fees or not responding to a request

 

 

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1for such data in a reasonable time frame; nor penalize a health
2care provider or professional for disclosing such information
3to a covered individual or legally prescribing, administering,
4or ordering a clinically appropriate or lower cost
5alternative.
6    (h) Nothing in this Section shall be construed to limit
7access to the most up-to-date patient-specific eligibility or
8patient-specific prescription cost and benefit data by the
9pharmacy benefit manager.
10    (i) Nothing in this Section shall interfere with patient
11choice and a health care professional's ability to convey the
12full range of prescription drug cost options to a patient. A
13pharmacy benefit manager shall not restrict a health care
14professional from communicating prescription cost options to
15the patient.
16    (j) No real-time benefit tool shall require a patient to
17use specific plan-preferred drugs or pharmacies.