99TH GENERAL ASSEMBLY
State of Illinois
2015 and 2016
SB1451

 

Introduced 2/20/2015, by Sen. Dan Kotowski

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5.12  from Ch. 23, par. 5-5.12

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that smoking cessation products shall not be subject to prior approval as a result of the 4-prescription limit.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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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
5changing Section 5-5.12 as follows:
 
6    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
7    Sec. 5-5.12. Pharmacy payments.
8    (a) Every request submitted by a pharmacy for reimbursement
9under this Article for prescription drugs provided to a
10recipient of aid under this Article shall include the name of
11the prescriber or an acceptable identification number as
12established by the Department.
13    (b) Pharmacies providing prescription drugs under this
14Article shall be reimbursed at a rate which shall include a
15professional dispensing fee as determined by the Illinois
16Department, plus the current acquisition cost of the
17prescription drug dispensed. The Illinois Department shall
18update its information on the acquisition costs of all
19prescription drugs no less frequently than every 30 days.
20However, the Illinois Department may set the rate of
21reimbursement for the acquisition cost, by rule, at a
22percentage of the current average wholesale acquisition cost.
23    (c) (Blank).

 

 

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1    (d) The Department shall review utilization of narcotic
2medications in the medical assistance program and impose
3utilization controls that protect against abuse.
4    (e) When making determinations as to which drugs shall be
5on a prior approval list, the Department shall include as part
6of the analysis for this determination, the degree to which a
7drug may affect individuals in different ways based on factors
8including the gender of the person taking the medication.
9    (f) The Department shall cooperate with the Department of
10Public Health and the Department of Human Services Division of
11Mental Health in identifying psychotropic medications that,
12when given in a particular form, manner, duration, or frequency
13(including "as needed") in a dosage, or in conjunction with
14other psychotropic medications to a nursing home resident or to
15a resident of a facility licensed under the ID/DD Community
16Care Act, may constitute a chemical restraint or an
17"unnecessary drug" as defined by the Nursing Home Care Act or
18Titles XVIII and XIX of the Social Security Act and the
19implementing rules and regulations. The Department shall
20require prior approval for any such medication prescribed for a
21nursing home resident or to a resident of a facility licensed
22under the ID/DD Community Care Act, that appears to be a
23chemical restraint or an unnecessary drug. The Department shall
24consult with the Department of Human Services Division of
25Mental Health in developing a protocol and criteria for
26deciding whether to grant such prior approval.

 

 

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1    (g) The Department may by rule provide for reimbursement of
2the dispensing of a 90-day supply of a generic or brand name,
3non-narcotic maintenance medication in circumstances where it
4is cost effective.
5    (g-5) On and after July 1, 2012, the Department may require
6the dispensing of drugs to nursing home residents be in a 7-day
7supply or other amount less than a 31-day supply. The
8Department shall pay only one dispensing fee per 31-day supply.
9    (h) Effective July 1, 2011, the Department shall
10discontinue coverage of select over-the-counter drugs,
11including analgesics and cough and cold and allergy
12medications.
13    (h-5) On and after July 1, 2012, the Department shall
14impose utilization controls, including, but not limited to,
15prior approval on specialty drugs, oncolytic drugs, drugs for
16the treatment of HIV or AIDS, immunosuppressant drugs, and
17biological products in order to maximize savings on these
18drugs. The Department may adjust payment methodologies for
19non-pharmacy billed drugs in order to incentivize the selection
20of lower-cost drugs. For drugs for the treatment of AIDS, the
21Department shall take into consideration the potential for
22non-adherence by certain populations, and shall develop
23protocols with organizations or providers primarily serving
24those with HIV/AIDS, as long as such measures intend to
25maintain cost neutrality with other utilization management
26controls such as prior approval. For hemophilia, the Department

 

 

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1shall develop a program of utilization review and control which
2may include, in the discretion of the Department, prior
3approvals. The Department may impose special standards on
4providers that dispense blood factors which shall include, in
5the discretion of the Department, staff training and education;
6patient outreach and education; case management; in-home
7patient assessments; assay management; maintenance of stock;
8emergency dispensing timeframes; data collection and
9reporting; dispensing of supplies related to blood factor
10infusions; cold chain management and packaging practices; care
11coordination; product recalls; and emergency clinical
12consultation. The Department may require patients to receive a
13comprehensive examination annually at an appropriate provider
14in order to be eligible to continue to receive blood factor.
15    (i) On and after July 1, 2012, the Department shall reduce
16any rate of reimbursement for services or other payments or
17alter any methodologies authorized by this Code to reduce any
18rate of reimbursement for services or other payments in
19accordance with Section 5-5e.
20    (j) On and after July 1, 2012, the Department shall impose
21limitations on prescription drugs such that the Department
22shall not provide reimbursement for more than 4 prescriptions,
23including 3 brand name prescriptions, for distinct drugs in a
2430-day period, unless prior approval is received for all
25prescriptions in excess of the 4-prescription limit. Drugs in
26the following therapeutic classes shall not be subject to prior

 

 

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1approval as a result of the 4-prescription limit:
2immunosuppressant drugs, oncolytic drugs, anti-retroviral
3drugs, and, on or after July 1, 2014, antipsychotic drugs.
4Smoking cessation products shall not be subject to prior
5approval as a result of the 4-prescription limit. On or after
6July 1, 2014, the Department may exempt children with complex
7medical needs enrolled in a care coordination entity contracted
8with the Department to solely coordinate care for such
9children, if the Department determines that the entity has a
10comprehensive drug reconciliation program.
11    (k) No medication therapy management program implemented
12by the Department shall be contrary to the provisions of the
13Pharmacy Practice Act.
14    (l) Any provider enrolled with the Department that bills
15the Department for outpatient drugs and is eligible to enroll
16in the federal Drug Pricing Program under Section 340B of the
17federal Public Health Services Act shall enroll in that
18program. No entity participating in the federal Drug Pricing
19Program under Section 340B of the federal Public Health
20Services Act may exclude Medicaid from their participation in
21that program, although the Department may exclude entities
22defined in Section 1905(l)(2)(B) of the Social Security Act
23from this requirement.
24(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333,
25eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12;
2697-813, eff. 7-13-12; 98-463, eff. 8-16-13; 98-651, eff.

 

 

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16-16-14.)