SB3498 100TH GENERAL ASSEMBLY

LRB100 20562 SMS 35966 b

100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
SB3498

Introduced 2/16/2018, by Sen. Elgie R. Sims, Jr.

SYNOPSIS AS INTRODUCED:

215 ILCS 134/45.3 new

Amends the Managed Care Reform and Patient Rights Act. Requires a policy or plan sponsor to notify the prescribing physician and the patient in writing 60 days before making a formulary change that alters the terms of coverage or discontinues coverage for a prescribed drug that the patient is receiving. Contains provisions for receiving the notice electronically. Provides that a policy or plan sponsor may provide the patient with the written notification, along with a 60-day supply of the prescription drug, at the time the patient requests a refill. Provides that nothing in the provisions prohibits insurers or pharmacy benefit managers from using certain managed pharmacy care tools so long as an exception process is in place allowing the prescriber to petition for coverage a non-preferred drug if sufficient clinical reasons justify an exception to the normal protocol.

A BILL FOR

AN ACT concerning regulation.

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

Section 5. The Managed Care Reform and Patient Rights Act is amended by adding Section 45.3 as follows:

(215 ILCS 134/45.3 new)

Sec. 45.3. Provision of notice; formulary changes.

(a) At least 60 days before making a formulary change that alters the terms of coverage or discontinues coverage for a prescribed drug that a patient is receiving, a policy or plan sponsor must, to the extent possible, notify the prescribing physician and the patient, or the parent or guardian if the patient is a child, or the spouse of a patient who is authorized to consent to the treatment of the patient. The notification shall be in writing and shall disclose the formulary change, indicate that the prescribing physician may initiate an appeal, and include information regarding the procedure for the prescribing physician to initiate the policy or plan sponsor's appeal process.

(b) As an alternative to providing written notice, a policy or plan sponsor may provide the notice electronically if, and only if, the patient affirmatively elects to receive the notice electronically. The notification shall disclose the formulary change, indicate that the prescribing physician may initiate an appeal, and include information regarding the procedure for the prescribing physician to initiate the policy or plan sponsor's appeal process.

(c) At the time a patient requests a refill of the prescription drug, a policy or plan sponsor may provide the patient with the written notification required under subsection (a) along with a 60-day supply of the prescription drug under the same terms as previously allowed.

(d) Nothing in this Section shall prohibit insurers or pharmacy benefit managers from using managed pharmacy care tools, including, but not limited to, formulary tiers, generic substitution, therapeutic interchange, prior authorization, or step therapy, so long as an exception process is in place allowing the prescriber to petition for coverage of a non-preferred drug if sufficient clinical reasons justify an exception to the normal protocol.