Illinois General Assembly - Full Text of HB2919
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Full Text of HB2919  102nd General Assembly

HB2919 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
HB2919

 

Introduced 2/19/2021, by Rep. Deanne M. Mazzochi

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/513b1

    Amends the Illinois Insurance Code. Provides that upon request by a party contracting with a pharmacy benefit manager, the party has an annual right to audit compliance with the terms of the contract by the pharmacy benefit manager, including, but not limited to, full disclosure of any value provided by a pharmaceutical manufacturer to a pharmacy benefit manager or the parent, subsidiary, or affiliate company of a pharmacy benefit manager. Provides that upon request by a party contracting with a pharmacy benefit manager, a pharmacy benefit manager shall disclose the actual amounts paid by the pharmacy benefit manager to the pharmacy. Provides that a pharmacy benefit manager must provide notice to the party contracting with the pharmacy benefit manager of any consideration that the pharmacy benefit manager's parent, subsidiary, or affiliate companies receive from the manufacturer for dispense as written prescriptions once a generic or biologically similar product becomes available. Provides that any provision of a contract entered into, amended, or renewed on or after the effective date of the amendatory Act that is contrary to provisions concerning pharmacy benefit managers is unenforceable. Defines "value".


LRB102 14248 BMS 19600 b

 

 

A BILL FOR

 

HB2919LRB102 14248 BMS 19600 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
5changing 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
10in Section 19.5 of the Pharmacy Practice Act.
11    "Maximum allowable cost" means the maximum amount that a
12pharmacy benefit manager will reimburse a pharmacy for the
13cost of a drug.
14    "Maximum allowable cost list" means a list of drugs for
15which a maximum allowable cost has been established by a
16pharmacy benefit manager.
17    "Pharmacy benefit manager" means a person, business, or
18entity, including a wholly or partially owned or controlled
19subsidiary of a pharmacy benefit manager, that provides claims
20processing services or other prescription drug or device
21services, or both, for health benefit plans.
22    "Retail price" means the price an individual without
23prescription drug coverage would pay at a retail pharmacy, not

 

 

HB2919- 2 -LRB102 14248 BMS 19600 b

1including a pharmacist dispensing fee.
2    "Value" includes anything of value given, whether measured
3in dollars, in-kind exchanges, volume discounts, rebates,
4exclusive distribution agreements, profit sharing
5arrangements, and whether assessed to a particular product or
6as a generalized amount.
7    (b) A contract between a health insurer and a pharmacy
8benefit manager must require that the pharmacy benefit
9manager:
10        (1) Update maximum allowable cost pricing information
11    at least every 7 calendar days.
12        (2) Maintain a process that will, in a timely manner,
13    eliminate drugs from maximum allowable cost lists or
14    modify drug prices to remain consistent with changes in
15    pricing data used in formulating maximum allowable cost
16    prices and product availability.
17        (3) Provide access to its maximum allowable cost list
18    to each pharmacy or pharmacy services administrative
19    organization subject to the maximum allowable cost list.
20    Access may include a real-time pharmacy website portal to
21    be able to view the maximum allowable cost list. As used in
22    this Section, "pharmacy services administrative
23    organization" means an entity operating within the State
24    that contracts with independent pharmacies to conduct
25    business on their behalf with third-party payers. A
26    pharmacy services administrative organization may provide

 

 

HB2919- 3 -LRB102 14248 BMS 19600 b

1    administrative services to pharmacies and negotiate and
2    enter into contracts with third-party payers or pharmacy
3    benefit managers on behalf of pharmacies.
4        (4) Provide a process by which a contracted pharmacy
5    can appeal the provider's reimbursement for a drug subject
6    to maximum allowable cost pricing. The appeals process
7    must, at a minimum, include the following:
8            (A) A requirement that a contracted pharmacy has
9        14 calendar days after the applicable fill date to
10        appeal a maximum allowable cost if the reimbursement
11        for the drug is less than the net amount that the
12        network provider paid to the supplier of the drug.
13            (B) A requirement that a pharmacy benefit manager
14        must respond to a challenge within 14 calendar days of
15        the contracted pharmacy making the claim for which the
16        appeal has been submitted.
17            (C) A telephone number and e-mail address or
18        website to network providers, at which the provider
19        can contact the pharmacy benefit manager to process
20        and submit an appeal.
21            (D) A requirement that, if an appeal is denied,
22        the pharmacy benefit manager must provide the reason
23        for the denial and the name and the national drug code
24        number from national or regional wholesalers.
25            (E) A requirement that, if an appeal is sustained,
26        the pharmacy benefit manager must make an adjustment

 

 

HB2919- 4 -LRB102 14248 BMS 19600 b

1        in the drug price effective the date the challenge is
2        resolved and make the adjustment applicable to all
3        similarly situated network pharmacy providers, as
4        determined by the managed care organization or
5        pharmacy benefit manager.
6        (5) Allow a plan sponsor contracting with a pharmacy
7    benefit manager an annual right to audit compliance with
8    the terms of the contract by the pharmacy benefit manager,
9    including, but not limited to, full disclosure of any and
10    all rebate amounts secured, whether product specific or
11    generalized rebates, that were provided to the pharmacy
12    benefit manager by a pharmaceutical manufacturer.
13        (6) Allow a plan sponsor contracting with a pharmacy
14    benefit manager to request that the pharmacy benefit
15    manager disclose the actual amounts paid by the pharmacy
16    benefit manager to the pharmacy.
17        (7) Provide notice to the party contracting with the
18    pharmacy benefit manager of any consideration that the
19    pharmacy benefit manager, including its parent,
20    subsidiary, or affiliate companies, receives from the
21    manufacturer for dispense as written prescriptions once a
22    generic or biologically similar product becomes available.
23    (b-5) Upon request by a party contracting with a pharmacy
24benefit manager, the party has an annual right to audit
25compliance with the terms of the contract by the pharmacy
26benefit manager, including, but not limited to, full

 

 

HB2919- 5 -LRB102 14248 BMS 19600 b

1disclosure of any value provided by a pharmaceutical
2manufacturer to a pharmacy benefit manager or the parent,
3subsidiary, or affiliate company of a pharmacy benefit
4manager.
5    Upon request by a party contracting with a pharmacy
6benefit manager, a pharmacy benefit manager shall disclose the
7actual amounts paid by the pharmacy benefit manager to the
8pharmacy.
9    (c) In order to place a particular prescription drug on a
10maximum allowable cost list, the pharmacy benefit manager
11must, at a minimum, ensure that:
12        (1) if the drug is a generically equivalent drug, it
13    is listed as therapeutically equivalent and
14    pharmaceutically equivalent "A" or "B" rated in the United
15    States Food and Drug Administration's most recent version
16    of the "Orange Book" or have an NR or NA rating by
17    Medi-Span, Gold Standard, or a similar rating by a
18    nationally recognized reference;
19        (2) the drug is available for purchase by each
20    pharmacy in the State from national or regional
21    wholesalers operating in Illinois; and
22        (3) the drug is not obsolete.
23    (d) A pharmacy benefit manager is prohibited from limiting
24a pharmacist's ability to disclose whether the cost-sharing
25obligation exceeds the retail price for a covered prescription
26drug, and the availability of a more affordable alternative

 

 

HB2919- 6 -LRB102 14248 BMS 19600 b

1drug, if one is available in accordance with Section 42 of the
2Pharmacy Practice Act.
3    (e) A health insurer or pharmacy benefit manager shall not
4require an insured to make a payment for a prescription drug at
5the point of sale in an amount that exceeds the lesser of:
6        (1) the applicable cost-sharing amount; or
7        (2) the retail price of the drug in the absence of
8    prescription drug coverage.
9    (f) This Section applies to contracts entered into or
10renewed on or after July 1, 2020.
11    (g) This Section applies to any group or individual policy
12of accident and health insurance or managed care plan that
13provides coverage for prescription drugs and that is amended,
14delivered, issued, or renewed on or after July 1, 2020.
15    (h) Any provision of a contract entered into, amended, or
16renewed on or after the effective date of this amendatory Act
17of the 102nd General Assembly that is contrary to this Section
18is unenforceable.
19(Source: P.A. 101-452, eff. 1-1-20.)