99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
HB3605

 

Introduced , by Rep. Jaime M. Andrade, Jr. - Monique D. Davis - Robyn Gabel - Greg Harris, Sara Feigenholtz, et al.

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.23 new

    Amends the Illinois Insurance Code. Provides that insurers that issue individual and group accident and health policies that provides coverage for prescription drugs shall ensure that any required copayment or coinsurance applicable to drugs and rated as platinum, gold, or silver under federal regulations does not exceed $100 per month for up to a 30-day supply of any single drug, and $200 for plans rated as bronze level under federal regulations, 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 and Affordable Care Act. Provides that policies that provide coverage for prescription drugs and use a tiered formulary shall implement an exceptions process that allows enrollees to request an exception to the tiered cost-sharing structure. Effective January 1, 2016.


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A BILL FOR

 

HB3605LRB099 09045 MLM 29233 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
10percentage of the total cost of a drug.
11    "Copayment" means a cost-sharing amount set as a dollar
12value.
13    "Non-preferred drug" means a drug in a tier designed for
14certain drugs deemed non-preferred and therefore subject to
15higher cost-sharing amounts than preferred drugs.
16    "Preferred drug" means a drug in a tier designed for
17certain drugs deemed preferred and therefore subject to lower
18cost-sharing amounts than non-preferred drugs.
19    "Tiered formulary" means a formulary that provides
20coverage for prescription drugs as part of a policy of health
21and accident insurance for which cost sharing, deductibles, or
22coinsurance obligations are determined by category or tier of
23prescription drugs and includes at least 2 different tiers.

 

 

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1    (b) On or after the effective date of this amendatory Act
2of the 99th General Assembly, every insurer that amends,
3delivers, issues, or renews individual and group accident and
4health policies providing coverage for prescription drugs
5shall ensure that:
6        (1) for insurance plans rated platinum, gold, and
7    silver level, as defined in 45 CFR 156.140, and regardless
8    of whether or not the plan was acquired through an exchange
9    authorized under the federal Patient Protection and
10    Affordable Care Act, any required copayment or coinsurance
11    applicable to drugs does not exceed $100 per month for up
12    to a 30-day supply of any single drug; and
13        (2) for bronze plans, as defined in 45 CFR 156.140, and
14    regardless of whether or not the plan was acquired through
15    an exchange authorized under the federal Patient
16    Protection and Affordable Care Act, any required copayment
17    or coinsurance applicable to drugs does not exceed $200 per
18    month for up to a 30-day supply of any single drug.
19    (c) The limits described in subsection (b) of this Section
20shall be inclusive of any patient out-of-pocket spending,
21including payments towards any deductibles, copayments, or
22coinsurance and shall be applicable before any applicable
23deductible is reached.
24    (d) An insurance plan that meets the requirements for a
25catastrophic plan, as defined in 45 CFR 156.155(a), shall be
26exempt from the requirements of subsection (b) of this Section.

 

 

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1    (e) Subject to subsection (f) of this Section, the limits
2in subsection (b) of this Section shall apply at any point in
3the benefit design, including before any after any applicable
4deductible is reached.
5    (f) For any enrollee that is enrolled in a policy that, but
6for the requirements of subsection (b) of this Section, would
7be a high deductible health plan as defined in Section
8223(c)(2)(A) of the Internal Revenue Code of 1986, the limits
9described in subsection (b) of this Section shall be applicable
10only after the minimum annual deductible specified in Section
11223(c)(2)(A) of the Internal Revenue Code of 1986 is reached.
12    (g) An insurer that issues policies of accident and health
13insurance that provides coverage for prescription drugs shall
14implement an exceptions process that allows enrollees to
15request an exception to the formulary. An insurer may use its
16existing medical exceptions process to satisfy this
17requirement. Under such an exception, a non-formulary drug
18shall be deemed covered under the formulary if the prescribing
19physician determines that the formulary drug for treatment of
20the same condition either would not be as effective for the
21individual, or would have adverse effects for the individual,
22or both. If an enrollee is denied an exception, the denial
23shall be considered an adverse coverage determination and will
24be subject to the health plan internal and external review
25processes.
26    (h) On or after the effective date of this amendatory Act

 

 

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1of the 99th General Assembly, every insurer that amends,
2delivers, issues, or renews individual and group accident and
3health policies providing coverage for prescription drugs
4shall ensure that beneficiary's annual out-of-pocket
5expenditures for prescription drugs are limited to no more than
650% of the dollar amounts in effect under Section 1302(c)(1) of
7the federal Patient Protection and Affordable Care Act for
8self-only and family coverage, respectively.
9    (i) An insurer that issues policies of accident and health
10policies that provides coverage for prescription drugs and uses
11a tiered formulary shall implement an exceptions process that
12allows enrollees to request an exception to the tiered
13cost-sharing structure. Under an exception, a non-preferred
14drug may be covered under the cost sharing applicable for
15preferred drugs if the prescribing health care provider
16determines that the preferred drug for treatment of the same
17condition either would not be as effective for the individual,
18would have adverse effects for the individual, or both. If an
19enrollee is denied a cost-sharing exception, the denial shall
20be considered an adverse event and shall be subject to the
21health plan's internal review process.
22    (j) Nothing in this Section shall be construed to require
23an insurer that issues accident and health policies:
24        (1) provide coverage for any additional drugs not
25    otherwise required by law;
26        (2) implement specific utilization management

 

 

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1    techniques, such as prior authorization or step therapy; or
2        (3) cease utilization of tiered cost-sharing
3    structures, including those strategies used to incentivize
4    use of preventive services, disease management, and
5    low-cost treatment options.
6    (k) Nothing in this Section shall be construed to require a
7pharmacist to substitute a drug without the consent of the
8prescribing physician.
9    (l) The Director shall adopt rules outlining the
10enforcement processes for this Section.
 
11    Section 99. Effective date. This Act takes effect January
121, 2016.