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Full Text of SB2346  102nd General Assembly

SB2346 102ND GENERAL ASSEMBLY

  
  

 


 
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB2346

 

Introduced 2/26/2021, by Sen. Michael E. Hastings

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5.12  from Ch. 23, par. 5-5.12
305 ILCS 5/5-16.11

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services shall not require prior approval for any medication appropriately prescribed to treat schizophrenia or related illnesses and their associated conditions, that is not used as a chemical restraint or as an unnecessary drug. Provides that antipsychotic prescription medications, including long-acting medications, that are covered under the State's fee-for-service or managed care medical assistance programs and that are prescribed by a licensed physician, licensed psychiatrist, licensed psychologist, licensed advanced practice registered nurse, or a licensed or certified mental health provider with prescriptive authority to treat a mental health condition or disorder shall be provided without imposition of any prior authorization, other utilization management requirements, or any other restriction as specified under the amendatory Act. Requires managed care entities to use a pharmacy formulary that at least meets the requirements of the amendatory Act.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB2346LRB102 14773 KTG 20126 b

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 1. Reference to Act. This Act may be referred to as
5the Protecting Access to Medication Used to Treat Serious
6Mental Illness Act.
 
7    Section 5. The Illinois Public Aid Code is amended by
8changing Sections 5-5.12 and 5-16.11 as follows:
 
9    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
10    Sec. 5-5.12. Pharmacy payments.
11    (a) Every request submitted by a pharmacy for
12reimbursement under this Article for prescription drugs
13provided to a recipient of aid under this Article shall
14include the name of the prescriber or an acceptable
15identification number as established by the Department.
16    (b) Pharmacies providing prescription drugs under this
17Article shall be reimbursed at a rate which shall include a
18professional dispensing fee as determined by the Illinois
19Department, plus the current acquisition cost of the
20prescription drug dispensed. The Illinois Department shall
21update its information on the acquisition costs of all
22prescription drugs no less frequently than every 30 days.

 

 

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1However, the Illinois Department may set the rate of
2reimbursement for the acquisition cost, by rule, at a
3percentage of the current average wholesale acquisition cost.
4    (c) (Blank).
5    (d) The Department shall review utilization of narcotic
6medications in the medical assistance program and impose
7utilization controls that protect against abuse.
8    (e) When making determinations as to which drugs shall be
9on a prior approval list, the Department shall include as part
10of the analysis for this determination, the degree to which a
11drug may affect individuals in different ways based on factors
12including the gender of the person taking the medication.
13Drugs described in subsection (m) with respect to timely
14treatment of mental illness shall not be subject to prior
15approval.
16    (f) The Department shall cooperate with the Department of
17Public Health and the Department of Human Services Division of
18Mental Health in identifying psychotropic medications that,
19when given in a particular form, manner, duration, or
20frequency (including "as needed") in a dosage, or in
21conjunction with other psychotropic medications to a nursing
22home resident or to a resident of a facility licensed under the
23ID/DD Community Care Act or the MC/DD Act, may constitute a
24chemical restraint or an "unnecessary drug" as defined by the
25Nursing Home Care Act or Titles XVIII and XIX of the Social
26Security Act and the implementing rules and regulations. The

 

 

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1Department shall require prior approval for any such
2medication prescribed for a nursing home resident or to a
3resident of a facility licensed under the ID/DD Community Care
4Act or the MC/DD Act, that appears to be a chemical restraint
5or an unnecessary drug. The Department shall consult with the
6Department of Human Services Division of Mental Health in
7developing a protocol and criteria for deciding whether to
8grant such prior approval. The Department shall not require
9prior approval for any medication appropriately prescribed to
10treat schizophrenia or related illnesses and their associated
11conditions as described in subsection (m), that is not used as
12a chemical restraint or as an unnecessary drug.
13    (g) The Department may by rule provide for reimbursement
14of the dispensing of a 90-day supply of a generic or brand
15name, non-narcotic maintenance medication in circumstances
16where it is cost effective.
17    (g-5) On and after July 1, 2012, the Department may
18require the dispensing of drugs to nursing home residents be
19in a 7-day supply or other amount less than a 31-day supply.
20The Department shall pay only one dispensing fee per 31-day
21supply.
22    (h) Effective July 1, 2011, the Department shall
23discontinue coverage of select over-the-counter drugs,
24including analgesics and cough and cold and allergy
25medications.
26    (h-5) On and after July 1, 2012, the Department shall

 

 

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1impose utilization controls, including, but not limited to,
2prior approval on specialty drugs, oncolytic drugs, drugs for
3the treatment of HIV or AIDS, immunosuppressant drugs, and
4biological products in order to maximize savings on these
5drugs. The Department may adjust payment methodologies for
6non-pharmacy billed drugs in order to incentivize the
7selection of lower-cost drugs. For drugs for the treatment of
8AIDS, the Department shall take into consideration the
9potential for non-adherence by certain populations, and shall
10develop protocols with organizations or providers primarily
11serving those with HIV/AIDS, as long as such measures intend
12to maintain cost neutrality with other utilization management
13controls such as prior approval. For hemophilia, the
14Department shall develop a program of utilization review and
15control which may include, in the discretion of the
16Department, prior approvals. The Department may impose special
17standards on providers that dispense blood factors which shall
18include, in the discretion of the Department, staff training
19and education; patient outreach and education; case
20management; in-home patient assessments; assay management;
21maintenance of stock; emergency dispensing timeframes; data
22collection and reporting; dispensing of supplies related to
23blood factor infusions; cold chain management and packaging
24practices; care coordination; product recalls; and emergency
25clinical consultation. The Department may require patients to
26receive a comprehensive examination annually at an appropriate

 

 

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1provider in order to be eligible to continue to receive blood
2factor.
3    (i) On and after July 1, 2012, the Department shall reduce
4any rate of reimbursement for services or other payments or
5alter any methodologies authorized by this Code to reduce any
6rate of reimbursement for services or other payments in
7accordance with Section 5-5e.
8    (j) On and after July 1, 2012, the Department shall impose
9limitations on prescription drugs such that the Department
10shall not provide reimbursement for more than 4 prescriptions,
11including 3 brand name prescriptions, for distinct drugs in a
1230-day period, unless prior approval is received for all
13prescriptions in excess of the 4-prescription limit. Drugs in
14the following therapeutic classes shall not be subject to
15prior approval as a result of the 4-prescription limit:
16immunosuppressant drugs, oncolytic drugs, anti-retroviral
17drugs, and, on or after July 1, 2014, antipsychotic drugs. On
18or after July 1, 2014, the Department may exempt children with
19complex medical needs enrolled in a care coordination entity
20contracted with the Department to solely coordinate care for
21such children, if the Department determines that the entity
22has a comprehensive drug reconciliation program.
23    (k) No medication therapy management program implemented
24by the Department shall be contrary to the provisions of the
25Pharmacy Practice Act.
26    (l) Any provider enrolled with the Department that bills

 

 

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1the Department for outpatient drugs and is eligible to enroll
2in the federal Drug Pricing Program under Section 340B of the
3federal Public Health Service Services Act shall enroll in
4that program. No entity participating in the federal Drug
5Pricing Program under Section 340B of the federal Public
6Health Service Services Act may exclude Medicaid from their
7participation in that program, although the Department may
8exclude entities defined in Section 1905(l)(2)(B) of the
9Social Security Act from this requirement.
10    (m) For purposes of removing barriers to timely treatment
11of serious mental illnesses, antipsychotic prescription
12medications, including long-acting medications, that are
13covered under the State's fee-for-service or managed care
14medical assistance programs and that are prescribed by a
15licensed physician, licensed psychiatrist, licensed
16psychologist, licensed advanced practice registered nurse, or
17a licensed or certified mental health provider with
18prescriptive authority to treat a mental health condition or
19disorder specified in the most recent edition of the
20Diagnostic and Statistical Manual of Mental Disorders shall be
21provided without imposition of any prior authorization, other
22utilization management requirements, or any other restriction
23subject to subparagraph (f).
24(Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14;
2599-180, eff. 7-29-15; revised 9-2-20.)
 

 

 

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1    (305 ILCS 5/5-16.11)
2    Sec. 5-16.11. Uniform standards applied to managed care
3entities. Any managed care entity providing services under
4this Code shall use a pharmacy formulary that is no more
5restrictive than the Illinois Department's pharmaceutical
6program and that at least meets the requirements of subsection
7(m) of Section 5-5.12.
8(Source: P.A. 92-370, eff. 8-15-01.)