HB3787 103RD GENERAL ASSEMBLY

LRB103 30041 BMS 56462 b

103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB3787

Introduced 2/17/2023, by Rep. Camille Y. Lilly

SYNOPSIS AS INTRODUCED:

215 ILCS 5/513b1.5 new

Amends the Pharmacy Benefit Managers Article of the Illinois Insurance Code. Provides that a pharmacy benefit manager shall not: steer a beneficiary; order a covered individual to fill a prescription or receive pharmacy care services from an affiliated pharmacy; reimburse a pharmacy or pharmacist for a pharmaceutical product or pharmacist service in an amount less than the amount that the pharmacy benefit manager reimburses itself or an affiliate for providing the same product or services; offer or implement plan designs that require patients to use an affiliated pharmacy; or advertise, market, or promote a pharmacy by an affiliate to patients or prospective patients. Defines terms.

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 Illinois Insurance Code is amended by adding Section 513b1.5 as follows:

(215 ILCS 5/513b1.5 new)

Sec. 513b1.5. Steering prohibition.

(a) As used in this Section:

"Covered individual" means a member, participant, enrollee, contract holder, policyholder, or beneficiary of a carrier, insurer, or issuer who is provided a prescription drug benefit by the carrier, insurer, or issuer. "Covered individual" includes a dependent or other person provided a prescription drug benefit through a policy, contract, or plan for a covered individual.

"Pharmacy benefit management" means a service provided to covered entities to facilitate the provision of prescription drug benefits to covered individuals for dispensation within this State, including negotiating pricing and other terms with drug manufacturers and retail pharmacies. "Pharmacy benefit management" includes the following:

(1) claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to covered individuals for dispensation within this State;

(2) clinical formulary development and management services;

(3) rebate contracting and administration;

(4) certain covered individual compliance, therapeutic intervention, and generic substitution programs; and

(5) disease management programs.

"Pharmacy benefit manager" means any person that designs or administers the prescription drug or device benefit of one or more health plans on behalf of a third party irrespective of whether such entity identifies itself as a pharmacy benefit manager. "Pharmacy benefit manager" includes any agent, affiliate, or representative of a health plan or pharmacy benefit manager hired or contracted by a health plan or pharmacy benefit manager to assist in designing or administering the drug benefit and any wholly owned or partially owned or controlled subsidiary of a pharmacy benefit manager.

"Steer" includes, but is not limited to:

(1) requiring a beneficiary to use only a pharmacy, including a mail-order pharmacy, in which the pharmacy benefit manager maintains an ownership interest or control;

(2) offering or implementing a plan design that encourages a beneficiary to use a pharmacy in which the pharmacy benefit manager maintains an ownership interest or control, if such plan design increases costs for the beneficiary, including requiring a beneficiary to pay full costs for a prescription if the beneficiary chooses not to use a pharmacy owned or controlled by the pharmacy benefit manager;

(3) reimbursing a pharmacy or pharmacist for a pharmaceutical product or pharmacist service in an amount less than the amount that the pharmacy benefit manager reimburses itself or an affiliate for providing the same product or services; or

(4) any other actions determined by the Department by rule.

(b) A pharmacy benefit manager shall not:

(1) steer a beneficiary;

(2) order a covered individual to fill a prescription or receive pharmacy care services from an affiliated pharmacy;

(3) reimburse a pharmacy or pharmacist for a pharmaceutical product or pharmacist service in an amount less than the amount that the pharmacy benefit manager reimburses itself or an affiliate for providing the same product or services;

(4) offer or implement plan designs that require patients to use an affiliated pharmacy; or

(5) advertise, market, or promote a pharmacy by an affiliate to patients or prospective patients.