98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
HB6277

 

Introduced , by Rep. Jaime M. Andrade, Jr. - Robyn Gabel - Laura Fine - Marcus C. Evans, Jr. - Christian L. Mitchell, et al.

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.22 new

    Amends the Illinois Insurance Code. Provides that a health plan that provides coverage for prescription drugs shall ensure that any required copayment or coinsurance applicable to drugs on a specialty tier does not exceed $100 per month for up to a 30-day supply of any single drug and a beneficiary's annual out-of-pocket expenditures for prescription drugs are limited to no more than fifty percent of the dollar amounts in effect under specified provisions of the federal Affordable Care Act. Provides that a health plan that provides coverage for prescription drugs and uses a tiered formulary shall implement an exceptions process that allows enrollees to request an exception to the tiered cost-sharing structure. Provides that a health plan that provides coverage for prescription drugs shall not place all drugs in a given class on a specialty tier. Effective January 1, 2015.


LRB098 21541 MGM 60146 b

 

 

A BILL FOR

 

HB6277LRB098 21541 MGM 60146 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 adding
5Section 356z.22 as follows:
 
6    (215 ILCS 5/356z.22 new)
7    Sec. 356z.22. Specialty tier prescription coverage.
8    (a) As used in this Section:
9        "Coinsurance" means a cost-sharing amount set as a
10    percentage of the total cost of a drug.
11        "Copayment" means a cost-sharing amount set as a dollar
12    value.
13        "Non-preferred drug" means a drug in a tier designed
14    for certain drugs deemed non-preferred and therefore
15    subject to higher cost-sharing amounts than preferred
16    drugs.
17        "Preferred drug" means a drug in a tier designed for
18    certain drugs deemed preferred and therefore subject to
19    lower cost-sharing amounts than non-preferred drugs.
20        "Specialty tier" means a tier of cost sharing that
21    imposes cost-sharing obligations that exceed that amount
22    for non-preferred and preferred drugs.
23        "Tiered formulary" means a formulary that provides

 

 

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1    coverage for prescription drugs as part of a health plan
2    for which cost sharing, deductibles, or coinsurance
3    obligations are determined by category or tier of
4    prescription drugs and includes at least 2 different tiers.
5    (b) A health plan that provides coverage for prescription
6drugs shall ensure that:
7        (1) any required copayment or coinsurance applicable
8    to drugs on a specialty tier does not exceed $100 per month
9    for up to a 30-day supply of any single drug; this limit
10    shall be inclusive of any patient out-of-pocket spending,
11    including payments towards any deductibles, copayments, or
12    coinsurance; further this limit shall be applicable at any
13    point in the benefit design, including before and after any
14    applicable deductible is reached; and
15        (2) a beneficiary's annual out-of-pocket expenditures
16    for prescription drugs are limited to no more than 50% of
17    the dollar amounts in effect under Section 1302(c)(1) of
18    the federal Affordable Care Act for self-only and family
19    coverage, respectively.
20    (c) A health plan that provides coverage for prescription
21drugs and uses a tiered formulary shall implement an exceptions
22process that allows enrollees to request an exception to the
23tiered cost-sharing structure. Under an exception, a
24non-preferred drug may be covered under the cost sharing
25applicable for preferred drugs if the prescribing health care
26provider determines that the preferred drug for treatment of

 

 

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1the same condition either would not be as effective for the
2individual, would have adverse effects for the individual, or
3both. If an enrollee is denied a cost-sharing exception, the
4denial shall be considered an adverse event and shall be
5subject to the health plan's internal review process.
6    (d) A health plan that provides coverage for prescription
7drugs shall not place all drugs in a given class on a specialty
8tier.
9    (e) Nothing in this Section shall be construed to require a
10health plan to:
11        (1) provide coverage for any additional drugs not
12    otherwise required by law;
13        (2) implement specific utilization management
14    techniques, such as prior authorization or step therapy; or
15        (3) cease utilization of tiered cost-sharing
16    structures, including those strategies used to incentivize
17    use of preventive services, disease management, and
18    low-cost treatment options.
19    (f) Nothing in this Section shall be construed to require a
20pharmacist to substitute a drug without the consent of the
21prescribing physician.
22    (g) The Director shall adopt rules outlining the
23enforcement processes for this Section.
 
24    Section 99. Effective date. This Act takes effect January
251, 2015.