Sen. William Delgado

Filed: 3/7/2013

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 1807

2    AMENDMENT NO. ______. Amend Senate Bill 1807 as follows:
 
3on page 1, line 4, after "by", by inserting "changing Section
45-5.12 and by"; and
 
5on page 1, by inserting immediately below line 5 the following:
 
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 reimbursement
9under this Article for prescription drugs provided to a
10recipient of aid under this Article shall include the name of
11the prescriber or an acceptable identification number as
12established 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

 

 

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1Department, plus the current acquisition cost of the
2prescription drug dispensed. The Illinois Department shall
3update its information on the acquisition costs of all
4prescription drugs no less frequently than every 30 days.
5However, the Illinois Department may set the rate of
6reimbursement for the acquisition cost, by rule, at a
7percentage of the current average wholesale acquisition cost.
8    (c) (Blank).
9    (d) The Department shall review utilization of narcotic
10medications in the medical assistance program and impose
11utilization controls that protect against abuse.
12    (e) When making determinations as to which drugs shall be
13on a prior approval list, the Department shall include as part
14of the analysis for this determination, the degree to which a
15drug may affect individuals in different ways based on factors
16including the gender of the person taking the medication.
17    (f) The Department shall cooperate with the Department of
18Public Health and the Department of Human Services Division of
19Mental Health in identifying psychotropic medications that,
20when given in a particular form, manner, duration, or frequency
21(including "as needed") in a dosage, or in conjunction with
22other psychotropic medications to a nursing home resident or to
23a resident of a facility licensed under the ID/DD Community
24Care Act, may constitute a chemical restraint or an
25"unnecessary drug" as defined by the Nursing Home Care Act or
26Titles XVIII and XIX of the Social Security Act and the

 

 

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1implementing rules and regulations. The Department shall
2require prior approval for any such medication prescribed for a
3nursing home resident or to a resident of a facility licensed
4under the ID/DD Community Care Act, that appears to be a
5chemical restraint or an unnecessary drug. The Department shall
6consult with the Department of Human Services Division of
7Mental Health in developing a protocol and criteria for
8deciding whether to grant such prior approval.
9    (g) The Department may by rule provide for reimbursement of
10the dispensing of a 90-day supply of a generic or brand name,
11non-narcotic maintenance medication in circumstances where it
12is cost effective.
13    (g-5) On and after July 1, 2012, the Department may require
14the dispensing of drugs to nursing home residents be in a 7-day
15supply or other amount less than a 31-day supply. The
16Department shall pay only one dispensing fee per 31-day supply.
17    (h) Effective July 1, 2011, the Department shall
18discontinue coverage of select over-the-counter drugs,
19including analgesics and cough and cold and allergy
20medications.
21    (h-5) On and after July 1, 2012, the Department shall
22impose utilization controls, including, but not limited to,
23prior approval on specialty drugs, oncolytic drugs, drugs for
24the treatment of HIV or AIDS, immunosuppressant drugs, and
25biological products in order to maximize savings on these
26drugs. The Department may adjust payment methodologies for

 

 

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1non-pharmacy billed drugs in order to incentivize the selection
2of lower-cost drugs. For drugs for the treatment of AIDS, the
3Department shall take into consideration the potential for
4non-adherence by certain populations, and shall develop
5protocols with organizations or providers primarily serving
6those with HIV/AIDS, as long as such measures intend to
7maintain cost neutrality with other utilization management
8controls such as prior approval. For hemophilia, the Department
9shall develop a program of utilization review and control which
10may include, in the discretion of the Department, prior
11approvals. The Department may impose special standards on
12providers that dispense blood factors which shall include, in
13the discretion of the Department, staff training and education;
14patient outreach and education; case management; in-home
15patient assessments; assay management; maintenance of stock;
16emergency dispensing timeframes; data collection and
17reporting; dispensing of supplies related to blood factor
18infusions; cold chain management and packaging practices; care
19coordination; product recalls; and emergency clinical
20consultation. The Department may require patients to receive a
21comprehensive examination annually at an appropriate provider
22in order to be eligible to continue to receive blood factor.
23    (i) On and after July 1, 2012, the Department shall reduce
24any rate of reimbursement for services or other payments or
25alter any methodologies authorized by this Code to reduce any
26rate of reimbursement for services or other payments in

 

 

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1accordance with Section 5-5e.
2    (i) (Blank).
3    (j) On and after July 1, 2012, the Department shall impose
4limitations on prescription drugs such that the Department
5shall not provide reimbursement for more than 4 prescriptions,
6including 3 brand name prescriptions, for distinct drugs in a
730-day period, unless prior approval is received for all
8prescriptions in excess of the 4-prescription limit. Drugs in
9the following therapeutic classes shall not be subject to prior
10approval as a result of the 4-prescription limit:
11immunosuppressant drugs, oncolytic drugs, and anti-retroviral
12drugs. Antipsychotic and anticonvulsant drugs used to treat
13severe mental illness shall not be subject to prior approval as
14a result of the 4-prescription limit and shall not count toward
15the monthly prescription limit when used for the following
16mental disorders: post-traumatic stress disorder,
17schizophrenia, schizoaffective disorder, bipolar disorder, or
18panic disorder.
19    (k) No medication therapy management program implemented
20by the Department shall be contrary to the provisions of the
21Pharmacy Practice Act.
22    (l) Any provider enrolled with the Department that bills
23the Department for outpatient drugs and is eligible to enroll
24in the federal Drug Pricing Program under Section 340B of the
25federal Public Health Services Act shall enroll in that
26program. No entity participating in the federal Drug Pricing

 

 

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1Program under Section 340B of the federal Public Health
2Services Act may exclude Medicaid from their participation in
3that program, although the Department may exclude entities
4defined in Section 1905(l)(2)(B) of the Social Security Act
5from this requirement.
6(Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10;
796-1501, eff. 1-25-11; 97-38, eff. 6-28-11; 97-74, eff.
86-30-11; 97-333, eff. 8-12-11; 97-426, eff. 1-1-12; 97-689,
9eff. 6-14-12; 97-813, eff. 7-13-12; revised 8-3-12.)".