State of Illinois
2023 and 2024


Introduced 2/6/2023, by Sen. Laura M. Murphy


305 ILCS 5/5-5.12  from Ch. 23, par. 5-5.12

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that drugs prescribed to residents of the following facilities are not subject to prior approval as a result of the 4-prescription limit: (i) long-term care facilities as defined in the Nursing Home Care Act; (ii) community-integrated living arrangements as defined in the Community-Integrated Living Arrangements Licensure and Certification Act; (iii) supportive living facilities as defined in the Code; (iv) intermediate care facilities for persons with developmental disabilities as defined in the ID/DD Community Care Act; and (v) medically complex for the developmentally disabled facilities as defined in the MC/DD Act.

LRB103 25962 KTG 52314 b





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



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1    (d) The Department shall review utilization of narcotic
2medications in the medical assistance program and impose
3utilization controls that protect against abuse.
4    (e) When making determinations as to which drugs shall be
5on a prior approval list, the Department shall include as part
6of the analysis for this determination, the degree to which a
7drug may affect individuals in different ways based on factors
8including the gender of the person taking the medication.
9    (f) The Department shall cooperate with the Department of
10Public Health and the Department of Human Services Division of
11Mental Health in identifying psychotropic medications that,
12when given in a particular form, manner, duration, or
13frequency (including "as needed") in a dosage, or in
14conjunction with other psychotropic medications to a nursing
15home resident or to a resident of a facility licensed under the
16ID/DD Community Care Act or the MC/DD Act, may constitute a
17chemical restraint or an "unnecessary drug" as defined by the
18Nursing Home Care Act or Titles XVIII and XIX of the Social
19Security Act and the implementing rules and regulations. The
20Department shall require prior approval for any such
21medication prescribed for a nursing home resident or to a
22resident of a facility licensed under the ID/DD Community Care
23Act or the MC/DD Act, that appears to be a chemical restraint
24or an unnecessary drug. The Department shall consult with the
25Department of Human Services Division of Mental Health in
26developing a protocol and criteria for deciding whether to



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1grant such prior approval.
2    (g) The Department may by rule provide for reimbursement
3of the dispensing of a 90-day supply of a generic or brand
4name, non-narcotic maintenance medication in circumstances
5where it is cost effective.
6    (g-5) On and after July 1, 2012, the Department may
7require the dispensing of drugs to nursing home residents be
8in a 7-day supply or other amount less than a 31-day supply.
9The Department shall pay only one dispensing fee per 31-day
11    (h) Effective July 1, 2011, the Department shall
12discontinue coverage of select over-the-counter drugs,
13including analgesics and cough and cold and allergy
15    (h-5) On and after July 1, 2012, the Department shall
16impose utilization controls, including, but not limited to,
17prior approval on specialty drugs, oncolytic drugs, drugs for
18the treatment of HIV or AIDS, immunosuppressant drugs, and
19biological products in order to maximize savings on these
20drugs. The Department may adjust payment methodologies for
21non-pharmacy billed drugs in order to incentivize the
22selection of lower-cost drugs. For drugs for the treatment of
23AIDS, the Department shall take into consideration the
24potential for non-adherence by certain populations, and shall
25develop protocols with organizations or providers primarily
26serving those with HIV/AIDS, as long as such measures intend



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1to maintain cost neutrality with other utilization management
2controls such as prior approval. For hemophilia, the
3Department shall develop a program of utilization review and
4control which may include, in the discretion of the
5Department, prior approvals. The Department may impose special
6standards on providers that dispense blood factors which shall
7include, in the discretion of the Department, staff training
8and education; patient outreach and education; case
9management; in-home patient assessments; assay management;
10maintenance of stock; emergency dispensing timeframes; data
11collection and reporting; dispensing of supplies related to
12blood factor infusions; cold chain management and packaging
13practices; care coordination; product recalls; and emergency
14clinical consultation. The Department may require patients to
15receive a comprehensive examination annually at an appropriate
16provider in order to be eligible to continue to receive blood
18    (i) On and after July 1, 2012, the Department shall reduce
19any rate of reimbursement for services or other payments or
20alter any methodologies authorized by this Code to reduce any
21rate of reimbursement for services or other payments in
22accordance with Section 5-5e.
23    (j) On and after July 1, 2012, the Department shall impose
24limitations on prescription drugs such that the Department
25shall not provide reimbursement for more than 4 prescriptions,
26including 3 brand name prescriptions, for distinct drugs in a



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130-day period, unless prior approval is received for all
2prescriptions in excess of the 4-prescription limit. Drugs in
3the following therapeutic classes shall not be subject to
4prior approval as a result of the 4-prescription limit:
5immunosuppressant drugs, oncolytic drugs, anti-retroviral
6drugs, and, on or after July 1, 2014, antipsychotic drugs. On
7or after July 1, 2014, the Department may exempt children with
8complex medical needs enrolled in a care coordination entity
9contracted with the Department to solely coordinate care for
10such children, if the Department determines that the entity
11has a comprehensive drug reconciliation program.
12    Drugs prescribed to residents of the following facilities
13are not subject to prior approval as a result of the
144-prescription limit:
15        (1) Long-term care facilities as defined in Section
16    1-113 of the Nursing Home Care Act.
17        (2) Community-integrated living arrangements as
18    defined in subsection (d) of Section 3 of the
19    Community-Integrated Living Arrangements Licensure and
20    Certification Act.
21        (3) Supportive living facilities as defined in Section
22    5-5.01a of this Code.
23        (4) Intermediate care facilities for persons with
24    developmental disabilities as defined in Section 1-113 of
25    the ID/DD Community Care Act.
26        (5) Medically complex for the developmentally disabled



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1    facilities as defined in Section 1-113 of the MC/DD Act.
2    (k) No medication therapy management program implemented
3by the Department shall be contrary to the provisions of the
4Pharmacy Practice Act.
5    (l) Any provider enrolled with the Department that bills
6the Department for outpatient drugs and is eligible to enroll
7in the federal Drug Pricing Program under Section 340B of the
8federal Public Health Service Act shall enroll in that
9program. No entity participating in the federal Drug Pricing
10Program under Section 340B of the federal Public Health
11Service Act may exclude fee-for-service Medicaid from their
12participation in that program, however, entities defined in
13Section 1905(l)(2)(B) of the Social Security Act are excluded
14from this requirement. This subsection does not apply to
15outpatient drugs billed to Medicaid managed care
17(Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.)