Full Text of HB3787 103rd General Assembly
HB3787 103RD GENERAL ASSEMBLY |
| | 103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024 HB3787 Introduced 2/17/2023, by Rep. Camille Y. Lilly SYNOPSIS AS INTRODUCED: |
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Amends the Pharmacy Benefit Managers Article of the Illinois Insurance Code. Provides that a pharmacy benefit manager shall not: steer a beneficiary; order a covered individual to fill a prescription or receive pharmacy care services from an affiliated pharmacy; reimburse a pharmacy or pharmacist for a pharmaceutical product or pharmacist service in an amount less than the amount that the pharmacy benefit manager reimburses itself or an affiliate for providing the same product or services; offer or implement plan designs that require patients to use an affiliated pharmacy; or advertise, market, or promote a pharmacy by an affiliate to patients or prospective patients. Defines terms.
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| | A BILL FOR |
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| | | HB3787 | | LRB103 30041 BMS 56462 b |
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| 1 | | AN ACT concerning regulation.
| 2 | | Be it enacted by the People of the State of Illinois,
| 3 | | represented in the General Assembly:
| 4 | | Section 5. The Illinois Insurance Code is amended by | 5 | | adding Section 513b1.5 as follows: | 6 | | (215 ILCS 5/513b1.5 new) | 7 | | Sec. 513b1.5. Steering prohibition. | 8 | | (a) As used in this Section: | 9 | | "Covered individual" means a member, participant, | 10 | | enrollee, contract holder, policyholder, or beneficiary of a | 11 | | carrier, insurer, or issuer who is provided a prescription | 12 | | drug benefit by the carrier, insurer, or issuer. "Covered | 13 | | individual" includes a dependent or other person provided a | 14 | | prescription drug benefit through a policy, contract, or plan | 15 | | for a covered individual. | 16 | | "Pharmacy benefit management" means a service provided to | 17 | | covered entities to facilitate the provision of prescription | 18 | | drug benefits to covered individuals for dispensation within | 19 | | this State, including negotiating pricing and other terms with | 20 | | drug manufacturers and retail pharmacies. "Pharmacy benefit | 21 | | management" includes the following: | 22 | | (1) claims processing, retail network management, and | 23 | | payment of claims to pharmacies for prescription drugs |
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| 1 | | dispensed to covered individuals for dispensation within | 2 | | this State; | 3 | | (2) clinical formulary development and management | 4 | | services; | 5 | | (3) rebate contracting and administration; | 6 | | (4) certain covered individual compliance, therapeutic | 7 | | intervention, and generic substitution programs; and | 8 | | (5) disease management programs. | 9 | | "Pharmacy benefit manager" means any person that designs | 10 | | or administers the prescription drug or device benefit of one | 11 | | or more health plans on behalf of a third party irrespective of | 12 | | whether such entity identifies itself as a pharmacy benefit | 13 | | manager. "Pharmacy benefit manager" includes any agent, | 14 | | affiliate, or representative of a health plan or pharmacy | 15 | | benefit manager hired or contracted by a health plan or | 16 | | pharmacy benefit manager to assist in designing or | 17 | | administering the drug benefit and any wholly owned or | 18 | | partially owned or controlled subsidiary of a pharmacy benefit | 19 | | manager. | 20 | | "Steer" includes, but is not limited to: | 21 | | (1) requiring a beneficiary to use only a pharmacy, | 22 | | including a mail-order pharmacy, in which the pharmacy | 23 | | benefit manager maintains an ownership interest or | 24 | | control; | 25 | | (2) offering or implementing a plan design that | 26 | | encourages a beneficiary to use a pharmacy in which the |
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| 1 | | pharmacy benefit manager maintains an ownership interest | 2 | | or control, if such plan design increases costs for the | 3 | | beneficiary, including requiring a beneficiary to pay full | 4 | | costs for a prescription if the beneficiary chooses not to | 5 | | use a pharmacy owned or controlled by the pharmacy benefit | 6 | | manager; | 7 | | (3) reimbursing a pharmacy or pharmacist for a | 8 | | pharmaceutical product or pharmacist service in an amount | 9 | | less than the amount that the pharmacy benefit manager | 10 | | reimburses itself or an affiliate for providing the same | 11 | | product or services; or | 12 | | (4) any other actions determined by the Department by | 13 | | rule. | 14 | | (b) A pharmacy benefit manager shall not: | 15 | | (1) steer a beneficiary; | 16 | | (2) order a covered individual to fill a prescription | 17 | | or receive pharmacy care services from an affiliated | 18 | | pharmacy; | 19 | | (3) reimburse a pharmacy or pharmacist for a | 20 | | pharmaceutical product or pharmacist service in an amount | 21 | | less than the amount that the pharmacy benefit manager | 22 | | reimburses itself or an affiliate for providing the same | 23 | | product or services; | 24 | | (4) offer or implement plan designs that require | 25 | | patients to use an affiliated pharmacy; or | 26 | | (5) advertise, market, or promote a pharmacy by an |
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| 1 | | affiliate to patients or prospective patients.
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