Full Text of SB3740 101st General Assembly
SB3740 101ST GENERAL ASSEMBLY |
| | 101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020 SB3740 Introduced 2/14/2020, by Sen. Andy Manar SYNOPSIS AS INTRODUCED: |
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Amends the Illinois Insurance Code. Provides that a pharmacy benefit manager shall pay the full amount paid by a health insurer or health benefit plan for prescription drug coverage to a pharmacy for such prescription drugs, less the amount of the pharmacy benefit manager's administrative costs. Effective immediately.
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| | A BILL FOR |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | changing Section 513b1 as follows: | 6 | | (215 ILCS 5/513b1) | 7 | | Sec. 513b1. Pharmacy benefit manager contracts. | 8 | | (a) As used in this Section: | 9 | | "Biological product" has the meaning ascribed to that term | 10 | | in Section 19.5 of the Pharmacy Practice Act. | 11 | | "Maximum allowable cost" means the maximum amount that a | 12 | | pharmacy benefit manager will reimburse a pharmacy for the cost | 13 | | of a drug. | 14 | | "Maximum allowable cost list" means a list of drugs for | 15 | | which a maximum allowable cost has been established by a | 16 | | pharmacy benefit manager. | 17 | | "Pharmacy benefit manager" means a person, business, or | 18 | | entity, including a wholly or partially owned or controlled | 19 | | subsidiary of a pharmacy benefit manager, that provides claims | 20 | | processing services or other prescription drug or device | 21 | | services, or both, for health benefit plans. | 22 | | "Retail price" means the price an individual without | 23 | | prescription drug coverage would pay at a retail pharmacy, not |
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| 1 | | including a pharmacist dispensing fee. | 2 | | (b) A contract between a health insurer and a pharmacy | 3 | | benefit manager must require that the pharmacy benefit manager: | 4 | | (1) Update maximum allowable cost pricing information | 5 | | at least every 7 calendar days. | 6 | | (2) Maintain a process that will, in a timely manner, | 7 | | eliminate drugs from maximum allowable cost lists or modify | 8 | | drug prices to remain consistent with changes in pricing | 9 | | data used in formulating maximum allowable cost prices and | 10 | | product availability. | 11 | | (3) Provide access to its maximum allowable cost list | 12 | | to each pharmacy or pharmacy services administrative | 13 | | organization subject to the maximum allowable cost list. | 14 | | Access may include a real-time pharmacy website portal to | 15 | | be able to view the maximum allowable cost list. As used in | 16 | | this Section, "pharmacy services administrative | 17 | | organization" means an entity operating within the State | 18 | | that contracts with independent pharmacies to conduct | 19 | | business on their behalf with third-party payers. A | 20 | | pharmacy services administrative organization may provide | 21 | | administrative services to pharmacies and negotiate and | 22 | | enter into contracts with third-party payers or pharmacy | 23 | | benefit managers on behalf of pharmacies. | 24 | | (4) Provide a process by which a contracted pharmacy | 25 | | can appeal the provider's reimbursement for a drug subject | 26 | | to maximum allowable cost pricing. The appeals process |
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| 1 | | must, at a minimum, include the following: | 2 | | (A) A requirement that a contracted pharmacy has 14 | 3 | | calendar days after the applicable fill date to appeal | 4 | | a maximum allowable cost if the reimbursement for the | 5 | | drug is less than the net amount that the network | 6 | | provider paid to the supplier of the drug. | 7 | | (B) A requirement that a pharmacy benefit manager | 8 | | must respond to a challenge within 14 calendar days of | 9 | | the contracted pharmacy making the claim for which the | 10 | | appeal has been submitted. | 11 | | (C) A telephone number and e-mail address or | 12 | | website to network providers, at which the provider can | 13 | | contact the pharmacy benefit manager to process and | 14 | | submit an appeal. | 15 | | (D) A requirement that, if an appeal is denied, the | 16 | | pharmacy benefit manager must provide the reason for | 17 | | the denial and the name and the national drug code | 18 | | number from national or regional wholesalers. | 19 | | (E) A requirement that, if an appeal is sustained, | 20 | | the pharmacy benefit manager must make an adjustment in | 21 | | the drug price effective the date the challenge is | 22 | | resolved and make the adjustment applicable to all | 23 | | similarly situated network pharmacy providers, as | 24 | | determined by the managed care organization or | 25 | | pharmacy benefit manager. | 26 | | (5) Allow a plan sponsor contracting with a pharmacy |
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| 1 | | benefit manager an annual right to audit compliance with | 2 | | the terms of the contract by the pharmacy benefit manager, | 3 | | including, but not limited to, full disclosure of any and | 4 | | all rebate amounts secured, whether product specific or | 5 | | generalized rebates, that were provided to the pharmacy | 6 | | benefit manager by a pharmaceutical manufacturer. | 7 | | (6) Allow a plan sponsor contracting with a pharmacy | 8 | | benefit manager to request that the pharmacy benefit | 9 | | manager disclose the actual amounts paid by the pharmacy | 10 | | benefit manager to the pharmacy. | 11 | | (7) Provide notice to the party contracting with the | 12 | | pharmacy benefit manager of any consideration that the | 13 | | pharmacy benefit manager receives from the manufacturer | 14 | | for dispense as written prescriptions once a generic or | 15 | | biologically similar product becomes available. | 16 | | (c) In order to place a particular prescription drug on a | 17 | | maximum allowable cost list, the pharmacy benefit manager must, | 18 | | at a minimum, ensure that: | 19 | | (1) if the drug is a generically equivalent drug, it is | 20 | | listed as therapeutically equivalent and pharmaceutically | 21 | | equivalent "A" or "B" rated in the United States Food and | 22 | | Drug Administration's most recent version of the "Orange | 23 | | Book" or have an NR or NA rating by Medi-Span, Gold | 24 | | Standard, or a similar rating by a nationally recognized | 25 | | reference; | 26 | | (2) the drug is available for purchase by each pharmacy |
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| 1 | | in the State from national or regional wholesalers | 2 | | operating in Illinois; and | 3 | | (3) the drug is not obsolete. | 4 | | (d) A pharmacy benefit manager is prohibited from limiting | 5 | | a pharmacist's ability to disclose whether the cost-sharing | 6 | | obligation exceeds the retail price for a covered prescription | 7 | | drug, and the availability of a more affordable alternative | 8 | | drug, if one is available in accordance with Section 42 of the | 9 | | Pharmacy Practice Act. | 10 | | (e) A health insurer or pharmacy benefit manager shall not | 11 | | require an insured to make a payment for a prescription drug at | 12 | | the point of sale in an amount that exceeds the lesser of: | 13 | | (1) the applicable cost-sharing amount; or | 14 | | (2) the retail price of the drug in the absence of | 15 | | prescription drug coverage. | 16 | | (f) A pharmacy benefit manager shall pay the full amount | 17 | | paid by a health insurer or health benefit plan for | 18 | | prescription drug coverage to a pharmacy for such prescription | 19 | | drugs, less the amount of the pharmacy benefit manager's | 20 | | administrative costs. | 21 | | (g) (f) This Section applies to contracts entered into or | 22 | | renewed on or after the effective date of this amendatory Act | 23 | | of the 101st General Assembly July 1, 2020 . | 24 | | (h) (g) This Section applies to any group or individual | 25 | | policy of accident and health insurance or managed care plan | 26 | | that provides coverage for prescription drugs and that is |
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| 1 | | amended, delivered, issued, or renewed on or after the | 2 | | effective date of this amendatory Act of the 101st General | 3 | | Assembly July 1, 2020 .
| 4 | | (Source: P.A. 101-452, eff. 1-1-20 .)
| 5 | | Section 99. Effective date. This Act takes effect upon | 6 | | becoming law.
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