103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB3787

 

Introduced 2/17/2023, by Rep. Camille Y. Lilly

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/513b1.5 new

    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.


LRB103 30041 BMS 56462 b

 

 

A BILL FOR

 

HB3787LRB103 30041 BMS 56462 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5adding 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,
10enrollee, contract holder, policyholder, or beneficiary of a
11carrier, insurer, or issuer who is provided a prescription
12drug benefit by the carrier, insurer, or issuer. "Covered
13individual" includes a dependent or other person provided a
14prescription drug benefit through a policy, contract, or plan
15for a covered individual.
16    "Pharmacy benefit management" means a service provided to
17covered entities to facilitate the provision of prescription
18drug benefits to covered individuals for dispensation within
19this State, including negotiating pricing and other terms with
20drug manufacturers and retail pharmacies. "Pharmacy benefit
21management" 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
10or administers the prescription drug or device benefit of one
11or more health plans on behalf of a third party irrespective of
12whether such entity identifies itself as a pharmacy benefit
13manager. "Pharmacy benefit manager" includes any agent,
14affiliate, or representative of a health plan or pharmacy
15benefit manager hired or contracted by a health plan or
16pharmacy benefit manager to assist in designing or
17administering the drug benefit and any wholly owned or
18partially owned or controlled subsidiary of a pharmacy benefit
19manager.
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.