HB5492 104TH GENERAL ASSEMBLY

LRB104 18985 BAB 32430 b

104TH GENERAL ASSEMBLY
State of Illinois
2025 and 2026
HB5492

Introduced 2/13/2026, by Rep. Katie Stuart - Yolonda Morris - Dagmara Avelar

SYNOPSIS AS INTRODUCED:

5 ILCS 375/6.11
215 ILCS 5/356z.88 new
225 ILCS 85/45 new
305 ILCS 5/5-16.8

Amends the Illinois Insurance Code. Sets forth provisions requiring an individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 to provide coverage for up to a 12-month supply of prescription hormone therapy, and the necessary supplies for self-administration, that is prescribed by a network provider within the provider's scope of practice and dispensed at one time for an enrollee by a provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies. Amends the Pharmacy Practice Act. Provides that, notwithstanding any other provision of law, a dispensing provider or pharmacist shall dispense, at a patient's request, up to a 12-month supply of a prescription hormone therapy and the necessary supplies for self-administration pursuant to a valid prescription that specifies an initial quantity followed by periodic refills, except as specified. Amends the State Employees Group Insurance Act of 1971 and the Illinois Public Aid Code to require coverage under the provisions of those Acts.

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 State Employees Group Insurance Act of 1971 is amended by changing Section 6.11 as follows:

(5 ILCS 375/6.11)

(Text of Section before amendment by P.A. 104-1)

Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.70, 356z.71, 356z.74, 356z.76, and 356z.77, and 356z.80, 356z.81, 356z.82, 356z.83, 356z.84, 356z.85, and 356z.88 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 and Article XXXIIB of the Illinois Insurance Code; all other requirements of this Section shall be enforced by the Department of Central Management Services.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25; 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff. 1-1-25; 104-27, eff. 1-1-26, 104-42, eff. 8-1-25; 104-68, eff. 1-1-26; 104-73, eff. 1-1-26; 104-289, eff. 1-1-26; 104-324, eff. 1-1-26; 104-379, eff. 1-1-26; 104-417, eff. 8-15-25; revised 11-19-25.)

(Text of Section after amendment by P.A. 104-1)

Sec. 6.11. Required health benefits; Illinois Insurance Code requirements. The program of health benefits shall provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, 356z.70, 356z.71, 356z.74, 356z.76, and 356z.77, 356z.79, and 356z.80, 356z.81, 356z.82, 356z.83, 356z.84, 356z.85, and 356z.88 of the Illinois Insurance Code. The program of health benefits must comply with Sections 155.22a, 155.37, 355b, 356z.19, 370c, and 370c.1 and Article XXXIIB of the Illinois Insurance Code. The program of health benefits shall provide the coverage required under Section 356m of the Illinois Insurance Code and, for the employees of the State Employee Group Insurance Program only, the coverage as also provided in Section 6.11B of this Act. The Department of Insurance shall enforce the requirements of this Section with respect to Sections 370c and 370c.1 and Article XXXIIB of the Illinois Insurance Code; all other requirements of this Section shall be enforced by the Department of Central Management Services.

Rulemaking authority to implement Public Act 95-1045, if any, is conditioned on the rules being adopted in accordance with all provisions of the Illinois Administrative Procedure Act and all rules and procedures of the Joint Committee on Administrative Rules; any purported rule not so adopted, for whatever reason, is unauthorized.

(Source: P.A. 103-8, eff. 1-1-24; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25; 103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff. 1-1-25; 104-1, eff. 7-1-27; 104-27, eff. 1-1-26, 104-42, eff. 8-1-25; 104-68, eff. 1-1-26; 104-73, eff. 1-1-26; 104-289, eff. 1-1-26; 104-324, eff. 1-1-26; 104-379, eff. 1-1-26; 104-417, eff. 8-15-25; revised 11-19-25.)

Section 10. The Illinois Insurance Code is amended by adding Section 356z.88 as follows:

(215 ILCS 5/356z.88 new)

Sec. 356z.88. Coverage for prescription hormone therapy.

(a) For purposes of this Section, "prescription hormone therapy" means all drugs approved by the United States Food and Drug Administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels and the necessary supplies for self-administration. "Prescription hormone therapy" does not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.

(b)(1) An individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 shall provide coverage for up to a 12-month supply of prescription hormone therapy, and the necessary supplies for self-administration, that is prescribed by a network provider within the provider's scope of practice and dispensed at one time for an enrollee by a provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.

(2) This Section does not require an individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 to cover prescription hormone therapy provided by an out-of-network provider, pharmacy, or location licensed or otherwise authorized to dispense drugs or supplies, except as may otherwise be authorized by State or federal law or by the plan's policies governing out-of-network coverage. If prescriptions for medically necessary prescription hormone therapy are unavailable to a plan enrollee within the plan's network, the plan shall arrange for the prescription hormone therapy to be provided by an out-of-network provider.

(3) This Section does not prohibit an individual or group policy of accident and health insurance amended, delivered, issued, or renewed on or after January 1, 2028 from limiting refills that may be obtained in the last quarter of the plan year if a 12-month supply of the prescription hormone therapy has already been dispensed during the plan year.

(4) This Section does not require a provider to prescribe, furnish, or dispense 12 months of prescription hormone therapy at one time.

(5) To the extent not otherwise prohibited under this Section or State or federal law, health plans may apply drug utilization management strategies to prescription drugs covered under paragraph (1) of this subsection.

(6) If an individual or group policy of accident and health insurance amended, delivered, issued, or renewed in this State on or after January 1, 2028 delegates responsibilities under this Section to a contracted entity, including a medical group or independent practice association, the delegated entity shall comply with this Section.

(c) This Section does not deny or restrict the Department's authority to ensure plan compliance when an individual or group policy of accident and health insurance provides coverage for prescription hormone therapy.

Section 15. The Pharmacy Practice Act is amended by adding Section 45 as follows:

(225 ILCS 85/45 new)

Sec. 45. Prescription hormone therapy.

(a) For purposes of this Section, "prescription hormone therapy" means all drugs approved by the United States Food and Drug Administration that are used to medically suppress, increase, or replace hormones that the body is not producing at intended levels and the necessary supplies for self-administration. "Prescription hormone therapy" does not include glucagon-like peptide-1 and glucagon-like peptide-1 receptor agonists.

(b) Notwithstanding any other provision of law, a dispensing provider or pharmacist shall dispense, at a patient's request, up to a 12-month supply of a prescription hormone therapy and the necessary supplies for self-administration pursuant to a valid prescription that specifies an initial quantity followed by periodic refills, unless any of the following is true:

(1) The patient requests a smaller supply.

(2) The prescribing provider instructs that the patient must have a smaller supply.

(3) The prescribing provider temporarily limits refills to a 90-day supply due to an acute dispensing shortage, so long as those limits are rescinded at the first opportunity of a regularly reinstated, sustainable supply.

(4) The prescription hormone therapy is a controlled substance. If the prescription hormone therapy is a controlled substance, the pharmacist shall dispense the maximum supply allowed under State and federal law to be obtained at one time by the patient.

Section 45. The Illinois Public Aid Code is amended by changing Section 5-16.8 as follows:

(305 ILCS 5/5-16.8)

Sec. 5-16.8. Required health benefits. The medical assistance program shall (i) provide the post-mastectomy care benefits required to be covered by a policy of accident and health insurance under Section 356t and the coverage required under Sections 356g.5, 356q, 356u, 356w, 356x, 356z.6, 356z.26, 356z.29, 356z.32, 356z.33, 356z.34, 356z.35, 356z.46, 356z.47, 356z.51, 356z.53, 356z.59, 356z.60, 356z.61, 356z.64, 356z.67, 356z.71, and 356z.75, and 356z.80, 356z.84, 356z.85, and 356z.88 of the Illinois Insurance Code, (ii) be subject to the provisions of Sections 356z.19, 356z.44, 356z.49, 364.01, 370c, and 370c.1 of the Illinois Insurance Code, and (iii) be subject to the provisions of subsection (d-5) of Section 10 of the Network Adequacy and Transparency Act.

The Department, by rule, shall adopt a model similar to the requirements of Section 356z.39 of the Illinois Insurance Code.

On and after July 1, 2012, the Department shall reduce any rate of reimbursement for services or other payments or alter any methodologies authorized by this Code to reduce any rate of reimbursement for services or other payments in accordance with Section 5-5e.

To ensure full access to the benefits set forth in this Section, on and after January 1, 2016, the Department shall ensure that provider and hospital reimbursement for post-mastectomy care benefits required under this Section are no lower than the Medicare reimbursement rate.

(Source: P.A. 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24; 103-605, eff. 7-1-24; 103-703, eff. 1-1-25; 103-758, eff. 1-1-25; 103-1024, eff. 1-1-25; 104-73, eff. 1-1-26; 104-324, eff. 1-1-26; 104-379, eff. 1-1-26; 104-417, eff. 8-15-25; revised 11-21-25.)

Section 95. No acceleration or delay. Where this Act makes changes in a statute that is represented in this Act by text that is not yet or no longer in effect (for example, a Section represented by multiple versions), the use of that text does not accelerate or delay the taking effect of (i) the changes made by this Act or (ii) provisions derived from any other Public Act.