HB5769eng 100TH GENERAL ASSEMBLY

HB5769 Engrossed LRB100 18687 SMS 33918 b

AN ACT concerning regulation.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Illinois Insurance Code is amended by adding Section 364.3 as follows:

(215 ILCS 5/364.3 new)

Sec. 364.3. Insurer uniform electronic prior authorization form; prescription benefits.

(a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.

(b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2020, an insurer that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits.

(c) On or before July 1, 2019, the Department shall develop a uniform electronic prior authorization form that shall be used by commercial insurers. Notwithstanding any other provision of law to the contrary, on and after July 1, 2020, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits and every insurer shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits.

(d) The Department shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents commercial insurers, from at least one public meeting.

(e) The Department, in development of the uniform electronic prior authorization form, shall take into consideration the following:

(1) existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the Department; and

(2) national standards pertaining to electronic prior authorization.

(f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, an insurer fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours (if the patient has urgent medication needs) or within 72 hours (if the patient has regular medication needs), then the prior authorization request shall be deemed to have been granted.

Section 10. The Illinois Public Aid Code is amended by adding Section 5-5.12b as follows:

(305 ILCS 5/5-5.12b new)

Sec. 5-5.12b. Managed care organization uniform electronic prior authorization form; prescription benefits.

(a) As used in this Section, "prescribing provider" includes a provider authorized to write a prescription, as described in subsection (e) of Section 3 of the Pharmacy Practice Act, to treat a medical condition of an insured.

(b) Notwithstanding any other provision of law to the contrary, on and after July 1, 2020, a managed care organization that provides prescription drug benefits shall utilize and accept the uniform electronic prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits.

(c) On or before July 1, 2019, the Department of Healthcare and Family Services shall develop a uniform electronic prior authorization form that shall be used by managed care organizations. Notwithstanding any other provision of law to the contrary, on and after July 1, 2020, every prescribing provider must use the uniform electronic prior authorization form to request prior authorization for coverage of prescription drug benefits, and every managed care organization shall accept the uniform electronic prior authorization form as sufficient to request prior authorization for prescription drug benefits.

(d) The Department of Healthcare and Family Services shall develop the uniform electronic prior authorization form with input from interested parties, including, but not limited to, the following individuals appointed by the Director of Healthcare and Family Services: 2 psychiatrists recommended by a State organization that represents psychiatrists, 2 pharmacists recommended by a State organization that represents pharmacists, 2 physicians recommended by a State organization that represents physicians, 2 family physicians recommended by a State organization that represents family physicians, 2 pediatricians recommended by a State organization that represents pediatricians, and 2 representatives of the association that represents managed care organizations, from at least one public meeting.

(e) The Department of Healthcare and Family Services, in development of the uniform electronic prior authorization form, shall take into consideration the following:

(1) existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the Department of Healthcare and Family Services; and

(2) national standards pertaining to electronic prior authorization.

(f) If, upon receipt of a completed and accurate electronic prior authorization request from a prescribing provider pursuant to the submission of a uniform electronic prior authorization form, a managed care organization fails to use or accept the uniform electronic prior authorization form or fails to respond within 24 hours, then the prior authorization request shall be deemed to have been granted.