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1 | AN ACT concerning insurance.
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2 | Be it enacted by the People of the State of Illinois,
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3 | represented in the General Assembly:
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4 | Section 1. Short title. This Act may be cited as the Organ | ||||||
5 | Transplant Medication Notification Act. | ||||||
6 | Section 5. Applicability. This Act shall apply solely to | ||||||
7 | cases of immunosuppressive therapy when (i) an | ||||||
8 | immunosuppressant drug has been prescribed to a patient to | ||||||
9 | prevent the rejection of transplanted organs and
tissues and | ||||||
10 | (ii) as set forth in Section 15 of this Act, a prescribing | ||||||
11 | physician has indicated on a prescription "may not substitute". | ||||||
12 | This Act does not apply to medication orders issued for | ||||||
13 | immunosuppressant drugs for any in-patient care in a licensed | ||||||
14 | hospital. | ||||||
15 | Section 10. Definitions. For the purpose of this Act: | ||||||
16 | "Health insurance policy or health care service plan" means | ||||||
17 | any policy of health or accident insurance subject to the | ||||||
18 | provisions of the Illinois Insurance Code, Health Maintenance | ||||||
19 | Organization Act, Voluntary Health Services Plan Act, Counties | ||||||
20 | Code, Municipal Code, School Code, and State Employees Group | ||||||
21 | Insurance Act. | ||||||
22 | "Immunosuppressant drugs" mean drugs that are used in |
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1 | immunosuppressive therapy to inhibit or prevent the activity of | ||||||
2 | the immune system. "Immunosuppressant drugs" are used | ||||||
3 | clinically to prevent the rejection of transplanted organs and | ||||||
4 | tissues. "Immunosuppressant drugs" do not include drugs for the | ||||||
5 | treatment of autoimmune diseases or diseases that are most | ||||||
6 | likely of autoimmune origin. | ||||||
7 | Section 15. Quality assurance in patient care. In | ||||||
8 | accordance with the Pharmacy Practice Act, when a prescribing | ||||||
9 | physician has indicated on a prescription "may not substitute", | ||||||
10 | a health insurance policy or health care service plan that | ||||||
11 | covers immunosuppressant drugs may not require or cause a | ||||||
12 | pharmacist to interchange another immunosuppressant drug or | ||||||
13 | formulation issued on behalf of a person to inhibit or prevent | ||||||
14 | the activity of the immune system of a patient to prevent the | ||||||
15 | rejection of transplanted organs and tissues without | ||||||
16 | notification and the documented consent of the prescribing | ||||||
17 | physician and the patient, or the parent or guardian if the | ||||||
18 | patient is a child, or the spouse of a patient who is | ||||||
19 | authorized to consent to the treatment of the person. | ||||||
20 | Except as provided by subsections (a), (b), and (c) of | ||||||
21 | Section 20 of this Act, patient co-payments, deductibles, or | ||||||
22 | other
charges for the prescribed drug for which another | ||||||
23 | immunosuppressant drug or formulation is not interchanged | ||||||
24 | shall remain the same for the enrollment period established by | ||||||
25 | the health insurance policy or plan.
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1 | Section 20. Provision of notice; formulary changes. | ||||||
2 | (a) At least 60 days prior to making any formulary change | ||||||
3 | that alters the terms of coverage for a patient receiving | ||||||
4 | immunosuppressant drugs or discontinues coverage for a | ||||||
5 | prescribed immunosuppressant drug that a patient is receiving, | ||||||
6 | a policy or plan sponsor must, to the extent possible, notify | ||||||
7 | the prescribing physician and the patient, or the parent or | ||||||
8 | guardian if the patient is a child, or the spouse of a patient | ||||||
9 | who is authorized to consent to the treatment of the patient. | ||||||
10 | The notification shall be in writing and shall disclose the | ||||||
11 | formulary change, indicate that the prescribing physician may | ||||||
12 | initiate an appeal, and include information regarding the | ||||||
13 | procedure for the prescribing physician to initiate the policy | ||||||
14 | or plan sponsor's appeal process. | ||||||
15 | (b) As an alternative to providing written notice, a policy | ||||||
16 | or plan sponsor may provide the notice electronically if, and | ||||||
17 | only if, the patient affirmatively elects to receive such | ||||||
18 | notice electronically. The notification shall disclose the | ||||||
19 | formulary change, indicate that the prescribing physician may | ||||||
20 | initiate an appeal, and include information regarding the | ||||||
21 | procedure for the prescribing physician to initiate the policy | ||||||
22 | or plan sponsor's appeal process. | ||||||
23 | (c) At the time a patient requests a refill of the | ||||||
24 | immunosuppressant drug, a policy or plan sponsor may provide | ||||||
25 | the patient with the written notification required under |
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1 | subsection (a) of this Section along with a 60-day supply of | ||||||
2 | the immunosuppressant drug under the same terms as previously | ||||||
3 | allowed. | ||||||
4 | (d) Nothing in this Section shall prohibit insurers or | ||||||
5 | pharmacy benefit managers from using managed pharmacy care | ||||||
6 | tools, including, but not limited to, formulary tiers, generic | ||||||
7 | substitution, therapeutic interchange, prior authorization, or | ||||||
8 | step therapy, so long as an exception process is in place | ||||||
9 | allowing the prescriber to petition for coverage of a | ||||||
10 | non-preferred drug if sufficient clinical reasons justify an | ||||||
11 | exception to the normal protocol. |