SB1454sam006 98TH GENERAL ASSEMBLY

Sen. William Delgado

Filed: 5/17/2013

09800SB1454sam006 LRB098 09389 KTG 46113 a

AMENDMENT TO SENATE BILL 1454

AMENDMENT NO. ______. Amend Senate Bill 1454, AS AMENDED, with reference to page and line numbers of Senate Amendment No. 5, as follows:

on page 1, line 5, before "Section 5.", by inserting the following:

"Section 3. The Illinois Insurance Code is amended by adding Section 364.3 as follows:

(215 ILCS 5/364.3 new)

Sec. 364.3. Uniform prior authorization form; prescription benefits.

(a) Notwithstanding any other provision of law, on and after January 1, 2015, a health insurer that provides prescription drug benefits shall utilize and accept the prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits.

(b) If a health insurer fails to utilize or accept the prior authorization form, or fails to respond within 2 business days upon receipt of a completed prior authorization request from a prescribing provider, pursuant to the submission of the prior authorization form developed as described in subsection (c), the prior authorization request shall be deemed to have been granted.

(c) On or before July 1, 2014, the Department and the Department of Healthcare and Family Services shall jointly develop a uniform prior authorization form. Notwithstanding any other provision of law, on and after January 1, 2015, or 6 months after the form is developed, whichever is later, every prescribing provider may use that uniform prior authorization form to request prior authorization for coverage of prescription drug benefits and every health insurer shall accept that form as sufficient to request prior authorization for prescription drug benefits.

(d) The prior authorization form developed pursuant to subsection (c) shall meet the following criteria:

(1) The form shall not exceed 2 pages.

(2) The form shall be made electronically available by the Department and the health insurer.

(3) The completed form may also be electronically submitted from the prescribing provider to the health insurer.

(4) The Department and the Department of Healthcare and Family Services shall develop the form with input from interested parties from at least one public meeting.

(5) The Department and the Department of Healthcare and Family Services, in development of the standardized form, shall take into consideration the following:

(A) Existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the Department of Healthcare and Family Services.

(B) National standards pertaining to electronic prior authorization.

(e) For purposes of 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."; and

on page 2, immediately below line 16, by inserting the following:

"Section 9. 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. Uniform prior authorization form; prescription benefits.

(a) Notwithstanding any other provision of law, on and after January 1, 2015, a health care service plan that provides prescription drug benefits shall utilize and accept the prior authorization form developed pursuant to subsection (c) when requiring prior authorization for prescription drug benefits. This Section does not apply in the event that a physician or physician group has been delegated the financial risk for prescription drugs by a health care service plan and does not use a prior authorization process. This Section does not apply to a health care service plan, or to its affiliated providers, if the health care service plan owns and operates its pharmacies and does not use a prior authorization process for prescription drugs.

(b) If a health care service plan fails to utilize or accept the prior authorization form, or fails to respond within 2 business days upon receipt of a completed prior authorization request from a prescribing provider, pursuant to the submission of the prior authorization form developed as described in subsection (c), the prior authorization request shall be deemed to have been granted.

(c) On or before July 1, 2014, the Department and the Department of Insurance shall jointly develop a uniform prior authorization form. Notwithstanding any other provision of law, on and after January 1, 2015, or 6 months after the form is developed, whichever is later, every prescribing provider may use that uniform prior authorization form to request prior authorization for coverage of prescription drug benefits and every health care service plan shall accept that form as sufficient to request prior authorization for prescription drug benefits.

(d) The prior authorization form developed pursuant to subsection (c) shall meet the following criteria:

(1) The form shall not exceed 2 pages.

(2) The form shall be made electronically available by the Department and the health care service plan.

(3) The completed form may also be electronically submitted from the prescribing provider to the health care service plan.

(4) The Department and the Department of Insurance shall develop the form with input from interested parties from at least one public meeting.

(5) The Department and the Department of Insurance, in development of the standardized form, shall take into consideration the following:

(A) Existing prior authorization forms established by the federal Centers for Medicare and Medicaid Services and the Department.

(B) National standards pertaining to electronic prior authorization.

(e) For purposes of 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 enrollee.".