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Full Text of SB2611  98th General Assembly

SB2611 98TH GENERAL ASSEMBLY

  
  

 


 
98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB2611

 

Introduced 10/23/2013, by Sen. Michael E. Hastings

 

SYNOPSIS AS INTRODUCED:
 
305 ILCS 5/5-5.12  from Ch. 23, par. 5-5.12

    Amends the Medical Assistance Article of the Illinois Public Aid Code. In a provision concerning utilization management controls and prior approval on specialty drugs, provides that for drugs for the treatment of AIDS or severe mental illness (rather than for the treatment of AIDS), the Department of Healthcare and Family Services shall take into consideration the potential for non-adherence by certain populations, and shall develop protocols with organizations or providers primarily serving those with HIV/AIDS or those with severe mental illness (rather than those with HIV/AIDS), as long as such measures intend to maintain cost neutrality with other utilization management controls such as prior approval. In a provision concerning limitations on prescription drugs, provides that antipsychotic drugs used to treat severe mental illness shall not be subject to prior approval as a result of the 4-prescription limit and shall not count toward the monthly prescription limit when used for the following mental disorders: post-traumatic stress disorder, schizophrenia, schizoaffective disorder, bipolar disorder, or panic disorder. Effective immediately.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

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1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5.12 as follows:
 
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
16Department, plus the current acquisition cost of the
17prescription drug dispensed. The Illinois Department shall
18update its information on the acquisition costs of all
19prescription drugs no less frequently than every 30 days.
20However, the Illinois Department may set the rate of
21reimbursement for the acquisition cost, by rule, at a
22percentage of the current average wholesale acquisition cost.
23    (c) (Blank).

 

 

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1    (d) The Department shall review utilization of narcotic
2medications in the medical assistance program and impose
3utilization controls that protect against abuse.
4    (e) When making determinations as to which drugs shall be
5on a prior approval list, the Department shall include as part
6of the analysis for this determination, the degree to which a
7drug may affect individuals in different ways based on factors
8including the gender of the person taking the medication.
9    (f) The Department shall cooperate with the Department of
10Public Health and the Department of Human Services Division of
11Mental Health in identifying psychotropic medications that,
12when given in a particular form, manner, duration, or frequency
13(including "as needed") in a dosage, or in conjunction with
14other psychotropic medications to a nursing home resident or to
15a resident of a facility licensed under the ID/DD Community
16Care Act, may constitute a chemical restraint or an
17"unnecessary drug" as defined by the Nursing Home Care Act or
18Titles XVIII and XIX of the Social Security Act and the
19implementing rules and regulations. The Department shall
20require prior approval for any such medication prescribed for a
21nursing home resident or to a resident of a facility licensed
22under the ID/DD Community Care Act, that appears to be a
23chemical restraint or an unnecessary drug. The Department shall
24consult with the Department of Human Services Division of
25Mental Health in developing a protocol and criteria for
26deciding whether to grant such prior approval.

 

 

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1    (g) The Department may by rule provide for reimbursement of
2the dispensing of a 90-day supply of a generic or brand name,
3non-narcotic maintenance medication in circumstances where it
4is cost effective.
5    (g-5) On and after July 1, 2012, the Department may require
6the dispensing of drugs to nursing home residents be in a 7-day
7supply or other amount less than a 31-day supply. The
8Department shall pay only one dispensing fee per 31-day supply.
9    (h) Effective July 1, 2011, the Department shall
10discontinue coverage of select over-the-counter drugs,
11including analgesics and cough and cold and allergy
12medications.
13    (h-5) On and after July 1, 2012, the Department shall
14impose utilization controls, including, but not limited to,
15prior approval on specialty drugs, oncolytic drugs, drugs for
16the treatment of HIV or AIDS, immunosuppressant drugs, and
17biological products in order to maximize savings on these
18drugs. The Department may adjust payment methodologies for
19non-pharmacy billed drugs in order to incentivize the selection
20of lower-cost drugs. For drugs for the treatment of AIDS or
21severe mental illness, the Department shall take into
22consideration the potential for non-adherence by certain
23populations, and shall develop protocols with organizations or
24providers primarily serving those with HIV/AIDS or those with
25severe mental illness, as long as such measures intend to
26maintain cost neutrality with other utilization management

 

 

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1controls such as prior approval. For hemophilia, the Department
2shall develop a program of utilization review and control which
3may include, in the discretion of the Department, prior
4approvals. The Department may impose special standards on
5providers that dispense blood factors which shall include, in
6the discretion of the Department, staff training and education;
7patient outreach and education; case management; in-home
8patient assessments; assay management; maintenance of stock;
9emergency dispensing timeframes; data collection and
10reporting; dispensing of supplies related to blood factor
11infusions; cold chain management and packaging practices; care
12coordination; product recalls; and emergency clinical
13consultation. The Department may require patients to receive a
14comprehensive examination annually at an appropriate provider
15in order to be eligible to continue to receive blood factor.
16    (i) On and after July 1, 2012, the Department shall reduce
17any rate of reimbursement for services or other payments or
18alter any methodologies authorized by this Code to reduce any
19rate of reimbursement for services or other payments in
20accordance with Section 5-5e.
21    (j) On and after July 1, 2012, the Department shall impose
22limitations on prescription drugs such that the Department
23shall not provide reimbursement for more than 4 prescriptions,
24including 3 brand name prescriptions, for distinct drugs in a
2530-day period, unless prior approval is received for all
26prescriptions in excess of the 4-prescription limit. Drugs in

 

 

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1the following therapeutic classes shall not be subject to prior
2approval as a result of the 4-prescription limit:
3immunosuppressant drugs, oncolytic drugs, and anti-retroviral
4drugs. Antipsychotic drugs used to treat severe mental illness
5shall not be subject to prior approval as a result of the
64-prescription limit and shall not count toward the monthly
7prescription limit when used for the following mental
8disorders: post-traumatic stress disorder, schizophrenia,
9schizoaffective disorder, bipolar disorder, or panic disorder.
10    (k) No medication therapy management program implemented
11by the Department shall be contrary to the provisions of the
12Pharmacy Practice Act.
13    (l) Any provider enrolled with the Department that bills
14the Department for outpatient drugs and is eligible to enroll
15in the federal Drug Pricing Program under Section 340B of the
16federal Public Health Services Act shall enroll in that
17program. No entity participating in the federal Drug Pricing
18Program under Section 340B of the federal Public Health
19Services Act may exclude Medicaid from their participation in
20that program, although the Department may exclude entities
21defined in Section 1905(l)(2)(B) of the Social Security Act
22from this requirement.
23(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333,
24eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12;
2597-813, eff. 7-13-12; 98-463, eff. 8-16-13.)
 
26    Section 99. Effective date. This Act takes effect upon

 

 

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1becoming law.