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| | 98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014 HB3671 Introduced , by Rep. Mary E. Flowers SYNOPSIS AS INTRODUCED: |
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305 ILCS 5/5-5.12 | from Ch. 23, par. 5-5.12 |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to impose limitations on prescriptions drugs such that the Department shall not provide reimbursement for more than 4 prescriptions, including 3 brand name prescriptions, for distinct drugs in a 30-day period, unless prior approval is received for all prescriptions in excess of the 4-prescription limit.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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| | HB3671 | | LRB098 13764 KTG 48293 b |
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1 | | AN ACT concerning public aid.
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2 | | Be it enacted by the People of the State of Illinois,
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3 | | represented in the General Assembly:
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4 | | Section 5. The Illinois Public Aid Code is amended by |
5 | | changing Section 5-5.12 as follows:
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6 | | (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
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7 | | Sec. 5-5.12. Pharmacy payments.
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8 | | (a) Every request submitted by a pharmacy for reimbursement |
9 | | under this
Article for prescription drugs provided to a |
10 | | recipient of aid under this
Article shall include the name of |
11 | | the prescriber or an acceptable
identification number as |
12 | | established by the Department.
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13 | | (b) Pharmacies providing prescription drugs under
this |
14 | | Article shall be reimbursed at a rate which shall include
a |
15 | | professional dispensing fee as determined by the Illinois
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16 | | Department, plus the current acquisition cost of the |
17 | | prescription
drug dispensed. The Illinois Department shall |
18 | | update its
information on the acquisition costs of all |
19 | | prescription drugs
no less frequently than every 30 days. |
20 | | However, the Illinois
Department may set the rate of |
21 | | reimbursement for the acquisition
cost, by rule, at a |
22 | | percentage of the current average wholesale
acquisition cost.
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23 | | (c) (Blank).
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1 | | (d) The Department shall review utilization of narcotic |
2 | | medications in the medical assistance program and impose |
3 | | utilization controls that protect against abuse.
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4 | | (e) When making determinations as to which drugs shall be |
5 | | on a prior approval list, the Department shall include as part |
6 | | of the analysis for this determination, the degree to which a |
7 | | drug may affect individuals in different ways based on factors |
8 | | including the gender of the person taking the medication. |
9 | | (f) The Department shall cooperate with the Department of |
10 | | Public Health and the Department of Human Services Division of |
11 | | Mental Health in identifying psychotropic medications that, |
12 | | when given in a particular form, manner, duration, or frequency |
13 | | (including "as needed") in a dosage, or in conjunction with |
14 | | other psychotropic medications to a nursing home resident or to |
15 | | a resident of a facility licensed under the ID/DD Community |
16 | | Care Act, may constitute a chemical restraint or an |
17 | | "unnecessary drug" as defined by the Nursing Home Care Act or |
18 | | Titles XVIII and XIX of the Social Security Act and the |
19 | | implementing rules and regulations. The Department shall |
20 | | require prior approval for any such medication prescribed for a |
21 | | nursing home resident or to a resident of a facility licensed |
22 | | under the ID/DD Community Care Act, that appears to be a |
23 | | chemical restraint or an unnecessary drug. The Department shall |
24 | | consult with the Department of Human Services Division of |
25 | | Mental Health in developing a protocol and criteria for |
26 | | deciding whether to grant such prior approval. |
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| | HB3671 | - 3 - | LRB098 13764 KTG 48293 b |
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1 | | (g) The Department may by rule provide for reimbursement of |
2 | | the dispensing of a 90-day supply of a generic or brand name, |
3 | | non-narcotic maintenance medication in circumstances where it |
4 | | is cost effective. |
5 | | (g-5) On and after July 1, 2012, the Department may require |
6 | | the dispensing of drugs to nursing home residents be in a 7-day |
7 | | supply or other amount less than a 31-day supply. The |
8 | | Department shall pay only one dispensing fee per 31-day supply. |
9 | | (h) Effective July 1, 2011, the Department shall |
10 | | discontinue coverage of select over-the-counter drugs, |
11 | | including analgesics and cough and cold and allergy |
12 | | medications. |
13 | | (h-5) On and after July 1, 2012, the Department shall |
14 | | impose utilization controls, including, but not limited to, |
15 | | prior approval on specialty drugs, oncolytic drugs, drugs for |
16 | | the treatment of HIV or AIDS, immunosuppressant drugs, and |
17 | | biological products in order to maximize savings on these |
18 | | drugs. The Department may adjust payment methodologies for |
19 | | non-pharmacy billed drugs in order to incentivize the selection |
20 | | of lower-cost drugs. For drugs for the treatment of AIDS, the |
21 | | Department shall take into consideration the potential for |
22 | | non-adherence by certain populations, and shall develop |
23 | | protocols with organizations or providers primarily serving |
24 | | those with HIV/AIDS, as long as such measures intend to |
25 | | maintain cost neutrality with other utilization management |
26 | | controls such as prior approval.
For hemophilia, the Department |
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1 | | shall develop a program of utilization review and control which |
2 | | may include, in the discretion of the Department, prior |
3 | | approvals. The Department may impose special standards on |
4 | | providers that dispense blood factors which shall include, in |
5 | | the discretion of the Department, staff training and education; |
6 | | patient outreach and education; case management; in-home |
7 | | patient assessments; assay management; maintenance of stock; |
8 | | emergency dispensing timeframes; data collection and |
9 | | reporting; dispensing of supplies related to blood factor |
10 | | infusions; cold chain management and packaging practices; care |
11 | | coordination; product recalls; and emergency clinical |
12 | | consultation. The Department may require patients to receive a |
13 | | comprehensive examination annually at an appropriate provider |
14 | | in order to be eligible to continue to receive blood factor. |
15 | | (i) On and after July 1, 2012, the Department shall reduce |
16 | | any rate of reimbursement for services or other payments or |
17 | | alter any methodologies authorized by this Code to reduce any |
18 | | rate of reimbursement for services or other payments in |
19 | | accordance with Section 5-5e. |
20 | | (i) (Blank). |
21 | | (j) (Blank). On and after July 1, 2012, the Department |
22 | | shall impose limitations on prescription drugs such that the |
23 | | Department shall not provide reimbursement for more than 4 |
24 | | prescriptions, including 3 brand name prescriptions, for |
25 | | distinct drugs in a 30-day period, unless prior approval is |
26 | | received for all prescriptions in excess of the 4-prescription |
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1 | | limit. Drugs in the following therapeutic classes shall not be |
2 | | subject to prior approval as a result of the 4-prescription |
3 | | limit: immunosuppressant drugs, oncolytic drugs, and |
4 | | anti-retroviral drugs. |
5 | | (k) No medication therapy management program implemented |
6 | | by the Department shall be contrary to the provisions of the |
7 | | Pharmacy Practice Act. |
8 | | (l) Any provider enrolled with the Department that bills |
9 | | the Department for outpatient drugs and is eligible to enroll |
10 | | in the federal Drug Pricing Program under Section 340B of the |
11 | | federal Public Health Services Act shall enroll in that |
12 | | program. No entity participating in the federal Drug Pricing |
13 | | Program under Section 340B of the federal Public Health |
14 | | Services Act may exclude Medicaid from their participation in |
15 | | that program, although the Department may exclude entities |
16 | | defined in Section 1905(l)(2)(B) of the Social Security Act |
17 | | from this requirement. |
18 | | (Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10; |
19 | | 96-1501, eff. 1-25-11; 97-38, eff. 6-28-11; 97-74, eff. |
20 | | 6-30-11; 97-333, eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, |
21 | | eff. 6-14-12; 97-813, eff. 7-13-12; revised 8-3-12.)
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