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Public Act 094-0086
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| SB0973 Enrolled |
LRB094 04657 DRJ 34686 b |
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AN ACT concerning aging.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Senior Citizens and Disabled Persons |
Property Tax Relief and Pharmaceutical Assistance Act is |
amended by changing Section 4 as follows:
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(320 ILCS 25/4) (from Ch. 67 1/2, par. 404)
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Sec. 4. Amount of Grant.
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(a) In general. Any individual 65 years or older or any |
individual who will
become 65 years old during the calendar |
year in which a claim is filed, and any
surviving spouse of |
such a claimant, who at the time of death received or was
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entitled to receive a grant pursuant to this Section, which |
surviving spouse
will become 65 years of age within the 24 |
months immediately following the
death of such claimant and |
which surviving spouse but for his or her age is
otherwise |
qualified to receive a grant pursuant to this Section, and any
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disabled person whose annual household income is less than |
$14,000 for grant
years before the 1998 grant year, less than |
$16,000 for the 1998 and 1999
grant years, and less than (i) |
$21,218 for a household containing one person,
(ii) $28,480 for |
a household containing 2 persons, or (iii) $35,740 for a
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household containing 3 or more persons for the 2000 grant year |
and thereafter
and whose household is liable for payment of |
property taxes accrued or has
paid rent constituting property |
taxes accrued and is domiciled in this State
at the time he or |
she files his or her claim is entitled to claim a
grant under |
this Act.
With respect to claims filed by individuals who will |
become 65 years old
during the calendar year in which a claim |
is filed, the amount of any grant
to which that household is |
entitled shall be an amount equal to 1/12 of the
amount to |
which the claimant would otherwise be entitled as provided in
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this Section, multiplied by the number of months in which the |
claimant was
65 in the calendar year in which the claim is |
filed.
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(b) Limitation. Except as otherwise provided in |
subsections (a) and (f)
of this Section, the maximum amount of |
grant which a claimant is
entitled to claim is the amount by |
which the property taxes accrued which
were paid or payable |
during the last preceding tax year or rent
constituting |
property taxes accrued upon the claimant's residence for the
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last preceding taxable year exceeds 3 1/2% of the claimant's |
household
income for that year but in no event is the grant to |
exceed (i) $700 less
4.5% of household income for that year for |
those with a household income of
$14,000 or less or (ii) $70 if |
household income for that year is more than
$14,000.
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(c) Public aid recipients. If household income in one or |
more
months during a year includes cash assistance in excess of |
$55 per month
from the Department of Public Aid or the |
Department of Human Services (acting
as successor to the |
Department of Public Aid under the Department of Human
Services |
Act) which was determined under regulations of
that Department |
on a measure of need that included an allowance for actual
rent |
or property taxes paid by the recipient of that assistance, the |
amount
of grant to which that household is entitled, except as |
otherwise provided in
subsection (a), shall be the product of |
(1) the maximum amount computed as
specified in subsection (b) |
of this Section and (2) the ratio of the number of
months in |
which household income did not include such cash assistance |
over $55
to the number twelve. If household income did not |
include such cash assistance
over $55 for any months during the |
year, the amount of the grant to which the
household is |
entitled shall be the maximum amount computed as specified in
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subsection (b) of this Section. For purposes of this paragraph |
(c), "cash
assistance" does not include any amount received |
under the federal Supplemental
Security Income (SSI) program.
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(d) Joint ownership. If title to the residence is held |
jointly by
the claimant with a person who is not a member of |
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his or her household,
the amount of property taxes accrued used |
in computing the amount of grant
to which he or she is entitled |
shall be the same percentage of property
taxes accrued as is |
the percentage of ownership held by the claimant in the
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residence.
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(e) More than one residence. If a claimant has occupied |
more than
one residence in the taxable year, he or she may |
claim only one residence
for any part of a month. In the case |
of property taxes accrued, he or she
shall prorate 1/12 of the |
total property taxes accrued on
his or her residence to each |
month that he or she owned and occupied
that residence; and, in |
the case of rent constituting property taxes accrued,
shall |
prorate each month's rent payments to the residence
actually |
occupied during that month.
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(f) There is hereby established a program of pharmaceutical |
assistance
to the aged and disabled which shall be administered |
by the Department in
accordance with this Act, to consist of |
payments to authorized pharmacies, on
behalf of beneficiaries |
of the program, for the reasonable costs of covered
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prescription drugs. Each beneficiary who pays $5 for an |
identification card
shall pay no additional prescription |
costs. Each beneficiary who pays $25 for
an identification card |
shall pay $3 per prescription. In addition, after a
beneficiary |
receives $2,000 in benefits during a State fiscal year, that
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beneficiary shall also be charged 20% of the cost of each |
prescription for
which payments are made by the program during |
the remainder of the fiscal
year. To become a beneficiary under |
this program a person must: (1)
be (i) 65 years of age or |
older, or (ii) the surviving spouse of such
a claimant, who at |
the time of death received or was entitled to receive
benefits |
pursuant to this subsection, which surviving spouse will become |
65
years of age within the 24 months immediately following the |
death of such
claimant and which surviving spouse but for his |
or her age is otherwise
qualified to receive benefits pursuant |
to this subsection, or (iii) disabled,
and (2) be domiciled in |
this State at the time he or she files
his or her claim, and (3) |
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have a maximum household income of less
than $14,000 for grant |
years before the 1998 grant year, less than $16,000
for the |
1998 and 1999 grant years, and less than (i) $21,218 for a |
household
containing one person, (ii) $28,480 for a household |
containing 2 persons, or
(iii) $35,740 for a household |
containing 3 more persons for the 2000 grant
year
and |
thereafter. In addition, each eligible person must (1) obtain |
an
identification card from the Department, (2) at the time the |
card is obtained,
sign a statement assigning to the State of |
Illinois benefits which may be
otherwise claimed under any |
private insurance plans, and (3) present the
identification |
card to the dispensing pharmacist.
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The Department may adopt rules specifying
participation
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requirements for the pharmaceutical assistance program, |
including copayment
amounts,
identification card fees, |
expenditure limits, and the benefit threshold after
which a 20% |
charge is imposed on the cost of each prescription, to be in
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effect on and
after July 1, 2004.
Notwithstanding any other |
provision of this paragraph, however, the Department
may not
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increase the identification card fee above the amount in effect |
on May 1, 2003
without
the express consent of the General |
Assembly.
To the extent practicable, those requirements shall |
be
commensurate
with the requirements provided in rules adopted |
by the Department of Public Aid
to
implement the pharmacy |
assistance program under Section 5-5.12a of the Illinois
Public
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Aid Code.
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Whenever a generic equivalent for a covered prescription |
drug is available,
the Department shall reimburse only for the |
reasonable costs of the generic
equivalent, less the co-pay |
established in this Section, unless (i) the covered
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prescription drug contains one or more ingredients defined as a |
narrow
therapeutic index drug at 21 CFR 320.33, (ii) the |
prescriber indicates on the
face of the prescription "brand |
medically necessary", and (iii) the prescriber
specifies that a |
substitution is not permitted. When issuing an oral
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prescription for covered prescription medication described in |
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item (i) of this
paragraph, the prescriber shall stipulate |
"brand medically necessary" and
that a substitution is not |
permitted. If the covered prescription drug and its
authorizing |
prescription do not meet the criteria listed above, the |
beneficiary
may purchase the non-generic equivalent of the |
covered prescription drug by
paying the difference between the |
generic cost and the non-generic cost plus
the beneficiary |
co-pay.
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Any person otherwise eligible for pharmaceutical |
assistance under this
Act whose covered drugs are covered by |
any public program for assistance in
purchasing any covered |
prescription drugs shall be ineligible for assistance
under |
this Act to the extent such costs are covered by such other |
plan.
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The fee to be charged by the Department for the |
identification card shall
be equal to $5 per coverage year for |
persons below the official poverty line
as defined by the |
United States Department of Health and Human Services and
$25 |
per coverage year for all other persons.
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In the event that 2 or more persons are eligible for any |
benefit under
this Act, and are members of the same household, |
(1) each such person shall
be entitled to participate in the |
pharmaceutical assistance program, provided
that he or she |
meets all other requirements imposed by this subsection
and (2) |
each participating household member contributes the fee |
required
for that person by the preceding paragraph for the |
purpose
of obtaining an identification card. |
The provisions of this subsection (f), other than this |
paragraph, are inoperative after December 31, 2005. |
Beneficiaries who received benefits under the program |
established by this subsection (f) are not entitled, at the |
termination of the program, to any refund of the identification |
card fee paid under this subsection. |
(g) Effective January 1, 2006, there is hereby established |
a program of pharmaceutical assistance to the aged and |
disabled, entitled the Illinois Seniors and Disabled Drug |
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Coverage Program, which shall be administered by the Department |
of Healthcare and Family Services and the Department on Aging |
in accordance with this subsection, to consist of coverage of |
specified prescription drugs on behalf of beneficiaries of the |
program as set forth in this subsection. The program under this |
subsection replaces and supersedes the program established |
under subsection (f), which shall end at midnight on December |
31, 2005. |
To become a beneficiary under the program established under |
this subsection, a person must: |
(1) be (i) 65 years of age or older or (ii) disabled; |
and |
(2) be domiciled in this State; and |
(3) enroll with a qualified Medicare Part D |
Prescription Drug Plan if eligible and apply for all |
available subsidies under Medicare Part D; and |
(4) have a maximum household income of (i) less than |
$21,218 for a household containing one person, (ii) less |
than $28,480 for a household containing 2 persons, or (iii) |
less than $35,740 for a household containing 3 or more |
persons. If any income eligibility limit set forth in items |
(i) through (iii) is less than 200% of the Federal Poverty |
Level for any year, the income eligibility limit for that |
year for households of that size shall be income equal to |
or less than 200% of the Federal Poverty Level. |
All individuals enrolled as of December 31, 2005, in the |
pharmaceutical assistance program operated pursuant to |
subsection (f) of this Section and all individuals enrolled as |
of December 31, 2005, in the SeniorCare Medicaid waiver program |
operated pursuant to Section 5-5.12a of the Illinois Public Aid |
Code shall be automatically enrolled in the program established |
by this subsection for the first year of operation without the |
need for further application, except that they must apply for |
Medicare Part D and the Low Income Subsidy under Medicare Part |
D. A person enrolled in the pharmaceutical assistance program |
operated pursuant to subsection (f) of this Section as of |
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December 31, 2005, shall not lose eligibility in future years |
due only to the fact that they have not reached the age of 65. |
To the extent permitted by federal law, the Department may |
act as an authorized representative of a beneficiary in order |
to enroll the beneficiary in a Medicare Part D Prescription |
Drug Plan if the beneficiary has failed to choose a plan and, |
where possible, to enroll beneficiaries in the low-income |
subsidy program under Medicare Part D or assist them in |
enrolling in that program. |
Beneficiaries under the program established under this |
subsection shall be divided into the following 4 eligibility |
groups: |
(A) Eligibility Group 1 shall consist of beneficiaries |
who are not eligible for Medicare Part D coverage and who
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are: |
(i) disabled and under age 65; or |
(ii) age 65 or older, with incomes over 200% of the |
Federal Poverty Level; or |
(iii) age 65 or older, with incomes at or below |
200% of the Federal Poverty Level and not eligible for |
federally funded means-tested benefits due to |
immigration status. |
(B) Eligibility Group 2 shall consist of beneficiaries |
otherwise described in Eligibility Group 1 but who are |
eligible for Medicare Part D coverage. |
(C) Eligibility Group 3 shall consist of beneficiaries |
age 65 or older, with incomes at or below 200% of the |
Federal Poverty Level, who are not barred from receiving |
federally funded means-tested benefits due to immigration |
status and are eligible for Medicare Part D coverage. |
(D) Eligibility Group 4 shall consist of beneficiaries |
age 65 or older, with incomes at or below 200% of the |
Federal Poverty Level, who are not barred from receiving |
federally funded means-tested benefits due to immigration |
status and are not eligible for Medicare Part D coverage. |
If the State applies and receives federal approval for a |
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waiver under Title XIX of the Social Security Act, persons in |
Eligibility Group 4 shall continue to receive benefits through |
the approved waiver, and Eligibility Group 4 may be expanded to |
include disabled persons under age 65 with incomes under 200% |
of the Federal Poverty Level who are not eligible for Medicare |
and who are not barred from receiving federally funded |
means-tested benefits due to immigration status. |
The program established under this subsection shall cover |
the cost of covered prescription drugs in excess of the |
beneficiary cost-sharing amounts set forth in this paragraph |
that are not covered by Medicare. In 2006, beneficiaries shall |
pay a co-payment of $2 for each prescription of a generic drug |
and $5 for each prescription of a brand-name drug. In future |
years, beneficiaries shall pay co-payments equal to the |
co-payments required under Medicare Part D for "other |
low-income subsidy eligible individuals" pursuant to 42 CFR |
423.782(b). Once the program established under this subsection |
and Medicare combined have paid $1,750 in a year for covered |
prescription drugs, the beneficiary shall pay 20% of the cost |
of each prescription in addition to the co-payments set forth |
in this paragraph. |
For beneficiaries eligible for Medicare Part D coverage, |
the program established under this subsection shall pay 100% of |
the premiums charged by a qualified Medicare Part D |
Prescription Drug Plan for Medicare Part D basic prescription |
drug coverage, not including any late enrollment penalties. |
Qualified Medicare Part D Prescription Drug Plans may be |
limited by the Department of Healthcare and Family Services to |
those plans that sign a coordination agreement with the |
Department. |
Notwithstanding Section 3.15, for purposes of the program |
established under this subsection, the term "covered |
prescription drug" has the following meanings: |
For Eligibility Group 1, "covered prescription drug" |
means: (1) any cardiovascular agent or drug; (2) any |
insulin or other prescription drug used in the treatment of |
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diabetes, including syringe and needles used to administer |
the insulin; (3) any prescription drug used in the |
treatment of arthritis; (4) any prescription drug used in |
the treatment of cancer; (5) any prescription drug used in |
the treatment of Alzheimer's disease; (6) any prescription |
drug used in the treatment of Parkinson's disease; (7) any |
prescription drug used in the treatment of glaucoma; (8) |
any prescription drug used in the treatment of lung disease |
and smoking-related illnesses; (9) any prescription drug |
used in the treatment of osteoporosis; and (10) any |
prescription drug used in the treatment of multiple |
sclerosis. The Department may add additional therapeutic |
classes by rule. The Department may adopt a preferred drug |
list within any of the classes of drugs described in items |
(1) through (10) of this paragraph. The specific drugs or |
therapeutic classes of covered prescription drugs shall be |
indicated by rule. |
For Eligibility Group 2, "covered prescription drug" |
means those drugs covered for Eligibility Group 1 that are |
also covered by the Medicare Part D Prescription Drug Plan |
in which the beneficiary is enrolled. |
For Eligibility Group 3, "covered prescription drug" |
means those drugs covered by the Medicare Part D |
Prescription Drug Plan in which the beneficiary is |
enrolled. |
For Eligibility Group 4, "covered prescription drug" |
means those drugs covered by the Medical Assistance Program |
under Article V of the Illinois Public Aid Code. |
An individual in Eligibility Group 3 or 4 may opt to |
receive a $25 monthly payment in lieu of the direct coverage |
described in this subsection. |
Any person otherwise eligible for pharmaceutical |
assistance under this subsection whose covered drugs are |
covered by any public program is ineligible for assistance |
under this subsection to the extent that the cost of those |
drugs is covered by the other program. |
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The Department of Healthcare and Family Services shall |
establish by rule the methods by which it will provide for the |
coverage called for in this subsection. Those methods may |
include direct reimbursement to pharmacies or the payment of a |
capitated amount to Medicare Part D Prescription Drug Plans. |
For a pharmacy to be reimbursed under the program |
established under this subsection, it must comply with rules |
adopted by the Department of Healthcare and Family Services |
regarding coordination of benefits with Medicare Part D |
Prescription Drug Plans. A pharmacy may not charge a |
Medicare-enrolled beneficiary of the program established under |
this subsection more for a covered prescription drug than the |
appropriate Medicare cost-sharing less any payment from or on |
behalf of the Department of Healthcare and Family Services. |
The Department of Healthcare and Family Services or the |
Department on Aging, as appropriate, may adopt rules regarding |
applications, counting of income, proof of Medicare status, |
mandatory generic policies, and pharmacy reimbursement rates |
and any other rules necessary for the cost-efficient operation |
of the program established under this subsection.
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(Source: P.A. 92-131, eff.
7-23-01; 92-519, eff. 1-1-02; |
92-651, eff. 7-11-02; 93-130, eff. 7-10-03.)
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Section 10. The Senior Citizens and Disabled Persons |
Prescription Drug Discount
Program Act is amended by changing |
the title of the Act and Sections 1, 5, 10, 15, 20, 25, 30, 35, |
40, 45, and 50 as follows:
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(320 ILCS 55/Act title)
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An Act concerning discount prescription drugs for Illinois |
residents
senior citizens.
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(320 ILCS 55/1)
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Sec. 1. Short title. This Act may be cited as the Illinois
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Senior Citizens
and
Disabled
Persons Prescription Drug |
Discount Program Act.
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(Source: P.A. 93-18, eff. 7-1-03.)
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(320 ILCS 55/5)
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Sec. 5. Findings. The General Assembly finds that:
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(a) (Blank).
Although senior citizens represent 12% of the |
population, they use on
average
37% of prescription drugs that |
are dispensed.
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(b) (Blank).
Senior citizens in the United States without |
prescription drug insurance
coverage pay the highest prices in |
the world for needed medications.
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(c) High prescription drug prices force many Illinois |
seniors to go without
proper
medication or other necessities, |
thereby affecting their health and safety.
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(d) Prescription drug prices in the United States are the |
world's highest,
averaging
32% higher than in Canada, 40% |
higher than in Mexico, and 60% higher than in
Great
Britain.
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(e) (Blank).
Regardless of household income, seniors |
without prescription drug
coverage
are often just one serious |
illness away from poverty.
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(f) Reducing the price of prescription drugs would benefit |
the health and
well-being of all Illinois residents
senior |
citizens by providing more affordable access
to needed drugs.
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(Source: P.A. 93-18, eff. 7-1-03.)
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(320 ILCS 55/10)
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Sec. 10. Purpose. The purpose of this program is to require |
the
Department
of
Healthcare and Family
Central Management
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Services to establish and administer a program that will
enable
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eligible Illinois residents
senior citizens and disabled |
persons to purchase prescription drugs at
discounted
prices.
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(Source: P.A. 93-18, eff. 7-1-03.)
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(320 ILCS 55/15)
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Sec. 15. Definitions. As used in this Act:
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"Authorized pharmacy" means any pharmacy registered in |
this State under the
Pharmacy Practice Act of 1987 or approved |
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by the Department of Financial and Professional Regulation and |
approved by the Department or its program
administrator.
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"AWP" or "average wholesale price" means the amount |
determined from the
latest publication of the Red Book, a |
universally subscribed pharmacist
reference guide
annually |
published by the Hearst Corporation. "AWP" or "average |
wholesale
price"
may also be derived electronically from the |
drug pricing database synonymous
with the
latest publication of |
the Red Book and furnished in the National Drug Data File
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(NDDF)
by First Data Bank (FDB), a service of the Hearst |
Corporation.
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"Covered medication" means any medication included in the |
Illinois Prescription Drug Discount Program.
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"Department" means the Department of Healthcare and Family
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Central Management Services.
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"Director" means the Director of Healthcare and Family
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Central Management Services.
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"Disabled person" means a person unable to engage in any |
substantial gainful
activity by reason of a medically |
determinable physical or mental impairment
which can
be |
expected to result in death or has lasted or can be expected to |
last for a
continuous
period of not less than 12 months.
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"Drug manufacturer" means any entity (1) that is located |
within or outside
Illinois
that is engaged in (i) the |
production, preparation, propagation, compounding,
conversion,
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or processing of prescription drug products covered under the |
program, either
directly or
indirectly by extraction from |
substances of natural origin, independently by
means of
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chemical synthesis, or by a combination of extraction and |
chemical synthesis or
(ii) the
packaging, repackaging, |
leveling, labeling, or distribution of prescription
drug |
products
covered under the program and (2) that elects to |
provide prescription drugs
either directly
or under contract |
with any entity providing prescription drug services on
behalf |
of the
State of Illinois. "Drug manufacturer", however, does |
not include a wholesale
distributor
of drugs or a retail |
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pharmacy licensed under Illinois law.
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"Federal Poverty Limit" or "FPL" means the Federal Poverty |
Income Guidelines published annually in the Federal Register.
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"Eligible senior" means a person who is (i) a resident of |
Illinois and (ii)
65 years of
age or older.
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"Prescription drug" means any prescribed drug that may be |
legally dispensed
by
an authorized pharmacy.
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"Program" means the Illinois
Senior Citizens and Disabled |
Persons Prescription Drug
Discount Program created
under this |
Act.
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"Program administrator" means the entity that is chosen by |
the Department to
administer the program. The program |
administrator may, in this case, be the
Director or
a Pharmacy |
Benefits Manager (PBM) chosen to subcontract with the Director.
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"Rules" includes rules adopted and forms prescribed by the |
Department.
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(Source: P.A. 93-18, eff. 7-1-03.)
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(320 ILCS 55/20)
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Sec. 20. The Illinois
Senior Citizens and Disabled Persons
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Prescription Drug
Discount
Program. The Illinois
Senior |
Citizens and Disabled Persons Prescription Drug Discount
|
Program
is established to protect the health and safety of |
Illinois residents
senior citizens and disabled
persons. The
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program shall be administered by the Department. The Department |
or its program
administrator shall (i) enroll eligible persons
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seniors and disabled persons into the
program, as provided in |
Section 35 of this Act, to
qualify them for a discount on the |
purchase of prescription drugs at an
authorized
pharmacy and
,
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(ii) enter into rebate agreements with drug manufacturers, as
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provided under Section 30 of this Act, and (iii) subject to the |
provisions of
Section 47 of this Act,
compensate pharmacies |
participating in the program
as provided under Section 25 of |
this Act.
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(Source: P.A. 93-18, eff. 7-1-03.)
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(320 ILCS 55/25)
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Sec. 25. Program administration.
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(a) The Department is authorized under this Act to be the |
program
administrator. If the Department is not the program |
administrator, 90 days
after the effective date of this Act, |
the Department must
issue a
request for proposals for bidders |
interested in administering the program.
Bidders must
compete |
on the basis of the following minimum criteria:
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(1) The Director shall solicit and accept proposals |
from entities
to provide for administration of a
program or |
programs in accordance with rules adopted under Section 45.
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Proposals must be submitted not later than a date |
established by the Director.
The
Director shall accept only |
those proposals that specify the following:
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(A) The estimated amount of the discount based on |
the AWP of the covered medications
entity's
previous |
experience and how the discount is to be achieved.
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(B) Administrative fees changed by the entity.
The |
extent that discounts on prescription drugs are to be
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achieved through rebates, administrative fees, or |
other fees or discounts in
prices that the entity |
negotiates
with drug manufacturers.
The proposals |
shall assure that rebates or discounts
will be
used to |
do the following:
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(i) reduce
costs to cardholders;
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(ii) achieve discounts for cardholders; and
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(iii) cover costs for administering the |
program.
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(C) Annual membership fees
Any other benefits |
offered to the cardholders.
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(D) The estimated number and geographic |
distribution of
participating pharmacies in the |
administrator's
pharmacy network.
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(E) The plan for pharmacy compensation, pursuant |
to subsection (e) of
this Section.
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(F) The method used for determining the |
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prescription drugs to be covered
by the program, and
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including the criteria and process for establishing a |
preferred
drug list, if
applicable.
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(G) How the entity proposes to improve medication |
management
for cardholders, including any program of |
disease management.
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(H) How cardholders and participating pharmacies
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will be
informed of the discounted price negotiated by |
the entity.
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(I) How the entity will handle complaints about the |
program's
operation.
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(J) The entity's previous experience in managing |
similar programs.
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(K) Any additional information requested by the |
Director.
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(2) The Director shall contract with one or more |
entities to administer
a
program or programs on the basis |
of the proposals submitted, but may require an
|
administrator to modify its conduct of a program in |
accordance with rules
adopted
under Section 45.
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The Director shall adopt rules specifying the period |
for which a contract
will be in effect and may terminate a |
contract if an administrator fails to
conduct a
program in |
accordance with its proposal or with any modifications |
required by
rule. When a contract period ends or a contract |
is terminated, the Director
shall
enter into a new contract |
in the manner specified in this Section for an
original
|
contract. Prior to making a new contract, the Director may |
modify the rules for
administration of the program or |
programs.
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(b) As used in this Section, "administrator" includes the |
administrator's
parent
company and any subsidiary of the parent |
company.
|
(1) No administrator shall sell any information |
concerning a person who
holds a prescription drug discount |
card, other than aggregate information that
does not |
|
identify the cardholder or the physician prescribing the |
medication, without the cardholder's written consent.
|
(2) Unless an administrator has the cardholder's |
written consent, no
administrator shall use any personally |
identifiable information that it obtains
concerning a |
cardholder through the program to promote or sell a program |
or
product offered by the administrator that is not related |
to the administration
of the
program. This subsection (b) |
does not prohibit an administrator from
contacting |
cardholders concerning participation in or administration |
of the
program, including, but not limited to, mailing a |
list of pharmacies
participating
in the program's network |
or participating in disease management programs.
|
(3) (Blank).
To the extent that a discount is achieved |
through rebates,
administrative fees, or any other fees or
|
discounts
in prices that an administrator negotiates with |
drug manufacturers, an
administrator shall use the rebates |
or discounts to do the following:
|
(A) reduce costs to cardholders;
|
(B) achieve discounts for cardholders; and
|
(C) cover any administrative costs of the program.
|
(4) The administrator shall not use any funds
generated |
from rebates, discounts, administrative fees, or other |
fees to
promote its mail order pharmacy operation or the |
mail order pharmacy operation
of an affiliate. This |
subdivision (b)(4) does not, however, limit the
|
participation of an
Illinois-licensed pharmacy under this |
Act if that pharmacy provides
prescription drugs by
mail |
order.
|
(c) (Blank).
Beginning on January 1, 2004, the amount paid |
by eligible seniors and
disabled persons enrolled in the |
program to authorized pharmacies for
prescription drugs
may not |
exceed prices established as a result of the rebate agreements |
under
Section 30.
The eligible seniors and disabled persons |
shall pay the price determined under
Section 30 plus
a |
dispensing fee of $3.50 per prescription for brand name drug |
|
products,
single-source drug products, and, for a period of 6 |
months, newly released
generic drug products and
$4.25 per |
prescription for all other generic drug products, except that |
the
total amount
paid
by the
eligible senior or disabled person |
for each prescription
drug under
this program shall not exceed |
the usual and customary charge for such
prescription.
|
(d) The contract between the Department and a pharmacy |
benefits manager
must,
at a minimum, meet the criteria of |
subsection (a). The contract must also
require
notification by |
the pharmacy benefits manager of any proposed or ongoing
|
activity that
involves, directly or indirectly, any conflict of |
interest on the part of the
pharmacy
benefits manager. The |
Department shall ensure that the pharmacy benefits
manager
|
complies with the contract and shall adopt all procedures |
necessary to enforce
the
contract.
|
(e) (Blank).
The Department or program administrator |
shall,
subject to the funds available
under
Section 30 of this |
Act,
compensate authorized
pharmacies for prescription drugs |
dispensed under the program
for the difference between the |
amount paid by the eligible senior or disabled
person for
|
prescription drugs
dispensed under the program and (i) the AWP |
minus 12% for
brand name drug products, single-source generic
|
drug products, and, for a period of 6 months,
newly released |
generic drug products
and (ii) the AWP minus 35% for all
other |
generic drug products.
The Department shall compensate a |
pharmacy under this subsection (e) only if
the amount paid by |
the eligible senior or disabled person
has been discounted to a |
price, including the dispensing fees stated in
subsection (c) |
of this Section, that
is less than (i) the
AWP
minus 12% for
|
brand name drug products, single-source generic
drug products, |
and, for a period of 6 months, newly released generic drug
|
products
and (ii) the AWP minus 35% for all
other
generic drug |
products.
|
(f) The
Beginning on January 1, 2004, the Department or |
program administrator
shall
reimburse pharmacies at negotiated |
rates based on market conditions
under this Section within 30 |
|
days after adjudication of
the
claim.
|
(Source: P.A. 93-18, eff. 7-1-03.)
|
(320 ILCS 55/30)
|
Sec. 30. Manufacturer rebate agreements.
|
(a) Taking into consideration the extent to which the State |
pays for
prescription
drugs under various State programs
and |
the provision of assistance to disabled persons or eligible |
seniors under
patient
assistance programs, prescription drug |
discount programs, or other offers for
free or
reduced price |
medicine, clinical research projects, limited supply |
distribution
programs,
compassionate use programs, or programs |
of research conducted by or for a drug
manufacturer, the |
Department, its agent, or the program
administrator shall |
negotiate and enter into rebate agreements with drug
|
manufacturers, as
defined in this Act, to effect prescription |
drug price discounts.
The Department or program administrator |
may exclude certain medications from the list of covered |
medications and may establish a preferred drug list as
a
basis
|
for determining the discounts, administrative fees, or other |
fees or rebates
under this Section.
|
(b) (Blank).
Rebate payment procedures. All rebates |
negotiated under agreements
described in this Section shall be |
paid in accordance with
procedures
prescribed by the Department |
or the program administrator.
|
(c) Receipts from rebates
shall be used
to provide |
discounts for prescription drugs purchased by cardholders
|
eligible seniors and
disabled persons and to cover the cost of |
administering the program,
including compensation to be paid to |
participating pharmacies by the Department
or program |
administrator under subsection (e) of Section 25. Any receipts |
to be
allocated to the Department shall be deposited into the |
Illinois
Senior Citizens and
Disabled Persons
Prescription |
Drug Discount Program Fund, a special fund hereby created in |
the
State treasury.
|
(Source: P.A. 93-18, eff. 7-1-03.)
|
|
(320 ILCS 55/35)
|
Sec. 35. Program eligibility.
|
(a) Any person may apply to the Department or its program |
administrator for
participation in the program in the form and |
manner required by the Department.
The
Department or its |
program administrator shall determine the eligibility of each
|
applicant
for the program within 30 days after the date of |
application. To participate in
the program
an eligible Illinois |
resident
senior or disabled person whose application has been |
approved must
pay the fee determined by the Director
$25
upon |
enrollment and annually thereafter and shall receive a program
|
identification card.
The card may be presented to an authorized |
pharmacy to assist the pharmacy in
verifying
eligibility under |
the program. If the Department is the program administrator, |
the
The Department shall deposit the enrollment fees
collected
|
into the Illinois
Senior Citizens and Disabled Persons
|
Prescription Drug Discount
Program Fund.
If the program |
administrator is a contracted vendor, the vendor may collect |
the enrollment fees and must report all such collected |
enrollment fees to the Department on a regular basis. The |
moneys collected by the Department for enrollment fees and
|
deposited into
the Senior
Citizens and Disabled Persons |
Prescription Drug Discount Program Fund must be
separately |
accounted for by the Department. If 2 or more persons are |
eligible
for any
benefit under this Act and are members of the |
same household, each
participating
household member shall |
apply to the Department and pay the fee required for the
|
purpose
of obtaining an identification card. To participate in |
the program, an applicant must (i) be a resident of Illinois |
and (ii) have household income equal to or less than 300% of |
the Federal Poverty Level.
|
(b) Proceeds from annual enrollment fees shall be
used
by |
the Department to offset the administrative cost of this Act. |
The Department
may
reduce the annual enrollment fee by rule if |
the revenue from the enrollment
fees is in
excess of the costs |
|
to carry out the program.
|
(c) (Blank).
Any person who is eligible for pharmaceutical |
assistance under the
Senior
Citizens and Disabled Persons |
Property Tax Relief and Pharmaceutical Assistance
Act is
|
presumed to be eligible for this program. The enrollment fee |
under this Act is
not required for such persons. That person |
may purchase prescription
drugs
under this program that are not |
covered by the pharmaceutical assistance
program under
the |
Senior Citizens and Disabled Persons Property Tax Relief and |
Pharmaceutical
Assistance Act by using the identification card |
issued under the pharmaceutical
assistance
program.
|
(Source: P.A. 93-18, eff. 7-1-03.)
|
(320 ILCS 55/40)
|
Sec. 40. Eligible pharmacies.
|
(a) The Department or its program administrator shall adopt |
rules to
establish
standards and procedures for participation |
in the program and approve those
pharmacies
that apply to |
participate and meet the requirements for participation.
|
Pharmacies in the
program administrator's network must also |
comply with the Department's
standards and
procedures for |
participation.
|
(b) The Department shall establish procedures for properly |
contracting for
pharmacy services, validating reimbursement |
claims, validating compliance of
authorized
pharmacies with |
the conditions for participation required under this Act, and
|
otherwise
providing for the effective administration of this |
Act. The Director, in
consultation with
pharmacists licensed |
under the Pharmacy Practice Act of 1987, may enter into a
|
written
contract with any other State agency, instrumentality, |
or political subdivision
or with a
fiscal intermediary for the |
purpose of making payments to authorized pharmacies
and |
coordinating the program with
other
programs that provide |
payments for prescription drugs covered under the
program.
|
(Source: P.A. 93-18, eff. 7-1-03.)
|
|
(320 ILCS 55/45)
|
Sec. 45. Rules. The Department shall adopt rules to |
implement and
administer
the program, which shall include the |
following:
|
(1) Execution of contracts with pharmacies to |
participate in the program.
The contracts shall stipulate |
terms and conditions for the participation of
authorized |
pharmacies and the rights of the State to terminate |
participation
for
breach of the contract or for violation |
of this Act or rules adopted by the
Department under this |
Act.
|
(2) Establishment of maximum limits on the size of |
prescriptions that are
eligible for a discount under the |
program, up to a 90-day supply, except as may
be
necessary |
for utilization control reasons.
|
(3) Inspection of appropriate records and audits of |
participating
authorized
pharmacies to ensure contract |
compliance and to determine any fraudulent
transactions or |
practices under this Act.
|
(4) Specify how a resident may apply to participate in |
the program.
|
(5) Specify the circumstances under which the Director |
may require an
administrator to modify its conduct of the |
program.
|
(6) Specify the duration of a contract.
|
(7) Require that an administrator permit any |
Illinois-licensed pharmacy
willing to comply
with the |
requirements of this Act and terms and conditions for |
participation in
the
program's
network to participate in |
the
any network used by the administrator for its
program.
|
(8) Permit an administrator to negotiate with one or |
more drug
manufacturers for discounts in drug prices or |
rebates.
|
(9) Permit an administrator to receive any rebate |
payments from drug
manufacturers.
|
(10) Permit an administrator to develop, administer, |
|
and promote a
program of disease management pursuant to |
written agreements between the
administrator and |
pharmacies participating under
the program established by |
this Act.
|
(11) Permit an administrator to collect the enrollment |
fee from applicants.
|
(Source: P.A. 93-18, eff. 7-1-03.)
|
(320 ILCS 55/50)
|
Sec. 50. Report on administration of program. The |
Department shall
report
to
the Governor and the General |
Assembly by March 1st of each year on the
administration
of the |
program under this Act.
The report shall include but not be |
limited to the following:
|
(1) the number of Illinois residents
disabled persons |
and seniors eligible and enrolled in
the
program, by |
county;
|
(2) the activities undertaken by the State to inform |
Illinois residents
disabled persons
and
seniors about the |
program;
|
(3) the number of prescriptions filled under the |
program for enrollees,
and
the estimated savings for |
enrollees;
|
(4) a listing of the manufacturers and pharmacies |
participating in the
program;
|
(5) the amount of enrollment fees and rebates collected |
under the
program, and any additional funds or resources |
made available to cover the cost
of the program;
|
(6) the itemized annual cost of administering the |
program; and
|
(7) findings and recommendations regarding problems |
and solutions
related to the program, together with |
proposals for changes in the rules,
regulations,
or laws |
necessary to improve the administration of the program.
|
(Source: P.A. 93-18, eff. 7-1-03.)
|