Full Text of HB3549 99th General Assembly
HB3549ham001 99TH GENERAL ASSEMBLY | Rep. Laura Fine Filed: 4/20/2015
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| 1 | | AMENDMENT TO HOUSE BILL 3549
| 2 | | AMENDMENT NO. ______. Amend House Bill 3549 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Managed Care Reform and Patient Rights Act | 5 | | is amended by changing Section 45.1 as follows: | 6 | | (215 ILCS 134/45.1) | 7 | | Sec. 45.1. Medical exceptions procedures required. | 8 | | (a) Notwithstanding any other provision of law, on or after | 9 | | the effective date of this amendatory Act of the 99th General | 10 | | Assembly, every insurer licensed in this State to sell a policy | 11 | | of group or individual accident and health insurance or a | 12 | | health benefits plan shall Every health carrier that offers a | 13 | | qualified health plan, as defined in the federal Patient | 14 | | Protection and Affordable Care Act of 2010 (Public Law | 15 | | 111-148), as amended by the federal Health Care and Education | 16 | | Reconciliation Act of 2010 (Public Law 111-152), and any |
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| 1 | | amendments thereto, or regulations or guidance issued under | 2 | | those Acts (collectively, "the Federal Act"), directly to | 3 | | consumers in this State shall establish and maintain a medical | 4 | | exceptions process that allows covered persons or their | 5 | | authorized representatives to request any clinically | 6 | | appropriate prescription drug when (1) the drug is not covered | 7 | | based on the health benefit plan's formulary; (2) the health | 8 | | benefit plan is discontinuing coverage of the drug on the | 9 | | plan's formulary for reasons other than safety or other than | 10 | | because the prescription drug has been withdrawn from the | 11 | | market by the drug's manufacturer; (3) the prescription drug | 12 | | alternatives required to be used in accordance with a step | 13 | | therapy requirement (A) has been ineffective in the treatment | 14 | | of the enrollee's disease or medical condition or, based on | 15 | | both sound clinical evidence and medical and scientific | 16 | | evidence, the known relevant physical or mental | 17 | | characteristics of the enrollee, and the known characteristics | 18 | | of the drug regimen, is likely to be ineffective or adversely | 19 | | affect the drug's effectiveness or patient compliance or (B) | 20 | | has caused or, based on sound medical evidence, is likely to | 21 | | cause an adverse reaction or harm to the enrollee; or (4) the | 22 | | number of doses available under a dose restriction for the | 23 | | prescription drug (A) has been ineffective in the treatment of | 24 | | the enrollee's disease or medical condition or (B) based on | 25 | | both sound clinical evidence and medical and scientific | 26 | | evidence, the known relevant physical and mental |
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| 1 | | characteristics of the enrollee, and known characteristics of | 2 | | the drug regimen, is likely to be ineffective or adversely | 3 | | affect the drug's effective or patient compliance. | 4 | | (b) The health carrier's established medical exceptions | 5 | | procedures must require, at a minimum, the following: | 6 | | (1) Any request for approval of coverage made verbally | 7 | | or in writing (regardless of whether made using a paper or | 8 | | electronic form or some other writing) at any time shall be | 9 | | reviewed by appropriate health care professionals. | 10 | | (2) The health carrier must, within 72 hours after | 11 | | receipt of a request made under subsection (a) of this | 12 | | Section, either approve or deny the request. In the case of | 13 | | a denial, the health carrier shall provide the covered | 14 | | person or the covered person's authorized representative | 15 | | and the covered person's prescribing provider with the | 16 | | reason for the denial, an alternative covered medication, | 17 | | if applicable, and information regarding the procedure for | 18 | | submitting an appeal to the denial. | 19 | | (3) In the case of an expedited coverage determination, | 20 | | the health carrier must either approve or deny the request | 21 | | within 24 hours after receipt of the request. In the case | 22 | | of a denial, the health carrier shall provide the covered | 23 | | person or the covered person's authorized representative | 24 | | and the covered person's prescribing provider with the | 25 | | reason for the denial, an alternative covered medication, | 26 | | if applicable, and information regarding the procedure for |
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| 1 | | submitting an appeal to the denial. | 2 | | (c) Notwithstanding any other provision of this Section, | 3 | | nothing in this Section shall be interpreted or implemented in | 4 | | a manner not consistent with the Federal Act.
| 5 | | (Source: P.A. 98-1035, eff. 8-25-14.)".
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