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| | 100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018 HB2511 Introduced , by Rep. Sara Feigenholtz SYNOPSIS AS INTRODUCED: |
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305 ILCS 5/5-5.12 | from Ch. 23, par. 5-5.12 |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that drugs prescribed for residents of licensed long-term care facilities shall not be subject to prior approval as a result of the 4-prescription limit.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | A BILL FOR |
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1 | | AN ACT concerning public aid.
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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 5. The Illinois Public Aid Code is amended by |
5 | | changing Section 5-5.12 as follows:
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6 | | (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
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7 | | Sec. 5-5.12. Pharmacy payments.
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8 | | (a) Every request submitted by a pharmacy for reimbursement |
9 | | under this
Article for prescription drugs provided to a |
10 | | recipient of aid under this
Article shall include the name of |
11 | | the prescriber or an acceptable
identification number as |
12 | | established by the Department.
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13 | | (b) Pharmacies providing prescription drugs under
this |
14 | | Article shall be reimbursed at a rate which shall include
a |
15 | | professional dispensing fee as determined by the Illinois
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16 | | Department, plus the current acquisition cost of the |
17 | | prescription
drug dispensed. The Illinois Department shall |
18 | | update its
information on the acquisition costs of all |
19 | | prescription drugs
no less frequently than every 30 days. |
20 | | However, the Illinois
Department may set the rate of |
21 | | reimbursement for the acquisition
cost, by rule, at a |
22 | | percentage of the current average wholesale
acquisition cost.
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23 | | (c) (Blank).
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1 | | (d) The Department shall review utilization of narcotic |
2 | | medications in the medical assistance program and impose |
3 | | utilization controls that protect against abuse.
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4 | | (e) When making determinations as to which drugs shall be |
5 | | on a prior approval list, the Department shall include as part |
6 | | of the analysis for this determination, the degree to which a |
7 | | drug may affect individuals in different ways based on factors |
8 | | including the gender of the person taking the medication. |
9 | | (f) The Department shall cooperate with the Department of |
10 | | Public Health and the Department of Human Services Division of |
11 | | Mental Health in identifying psychotropic medications that, |
12 | | when given in a particular form, manner, duration, or frequency |
13 | | (including "as needed") in a dosage, or in conjunction with |
14 | | other psychotropic medications to a nursing home resident or to |
15 | | a resident of a facility licensed under the ID/DD Community |
16 | | Care Act or the MC/DD Act, may constitute a chemical restraint |
17 | | or an "unnecessary drug" as defined by the Nursing Home Care |
18 | | Act or Titles XVIII and XIX of the Social Security Act and the |
19 | | implementing rules and regulations. The Department shall |
20 | | require prior approval for any such medication prescribed for a |
21 | | nursing home resident or to a resident of a facility licensed |
22 | | under the ID/DD Community Care Act or the MC/DD Act, that |
23 | | appears to be a chemical restraint or an unnecessary drug. The |
24 | | Department shall consult with the Department of Human Services |
25 | | Division of Mental Health in developing a protocol and criteria |
26 | | for deciding whether to grant such prior approval. |
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1 | | (g) The Department may by rule provide for reimbursement of |
2 | | the dispensing of a 90-day supply of a generic or brand name, |
3 | | non-narcotic maintenance medication in circumstances where it |
4 | | is cost effective. |
5 | | (g-5) On and after July 1, 2012, the Department may require |
6 | | the dispensing of drugs to nursing home residents be in a 7-day |
7 | | supply or other amount less than a 31-day supply. The |
8 | | Department shall pay only one dispensing fee per 31-day supply. |
9 | | (h) Effective July 1, 2011, the Department shall |
10 | | discontinue coverage of select over-the-counter drugs, |
11 | | including analgesics and cough and cold and allergy |
12 | | medications. |
13 | | (h-5) On and after July 1, 2012, the Department shall |
14 | | impose utilization controls, including, but not limited to, |
15 | | prior approval on specialty drugs, oncolytic drugs, drugs for |
16 | | the treatment of HIV or AIDS, immunosuppressant drugs, and |
17 | | biological products in order to maximize savings on these |
18 | | drugs. The Department may adjust payment methodologies for |
19 | | non-pharmacy billed drugs in order to incentivize the selection |
20 | | of lower-cost drugs. For drugs for the treatment of AIDS, the |
21 | | Department shall take into consideration the potential for |
22 | | non-adherence by certain populations, and shall develop |
23 | | protocols with organizations or providers primarily serving |
24 | | those with HIV/AIDS, as long as such measures intend to |
25 | | maintain cost neutrality with other utilization management |
26 | | controls such as prior approval.
For hemophilia, the Department |
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1 | | shall develop a program of utilization review and control which |
2 | | may include, in the discretion of the Department, prior |
3 | | approvals. The Department may impose special standards on |
4 | | providers that dispense blood factors which shall include, in |
5 | | the discretion of the Department, staff training and education; |
6 | | patient outreach and education; case management; in-home |
7 | | patient assessments; assay management; maintenance of stock; |
8 | | emergency dispensing timeframes; data collection and |
9 | | reporting; dispensing of supplies related to blood factor |
10 | | infusions; cold chain management and packaging practices; care |
11 | | coordination; product recalls; and emergency clinical |
12 | | consultation. The Department may require patients to receive a |
13 | | comprehensive examination annually at an appropriate provider |
14 | | in order to be eligible to continue to receive blood factor. |
15 | | (i) On and after July 1, 2012, the Department shall reduce |
16 | | any rate of reimbursement for services or other payments or |
17 | | alter any methodologies authorized by this Code to reduce any |
18 | | rate of reimbursement for services or other payments in |
19 | | accordance with Section 5-5e. |
20 | | (j) On and after July 1, 2012, the Department shall impose |
21 | | limitations on prescription drugs such that the Department |
22 | | shall not provide reimbursement for more than 4 prescriptions, |
23 | | including 3 brand name prescriptions, for distinct drugs in a |
24 | | 30-day period, unless prior approval is received for all |
25 | | prescriptions in excess of the 4-prescription limit. Drugs in |
26 | | the following therapeutic classes shall not be subject to prior |
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1 | | approval as a result of the 4-prescription limit: |
2 | | immunosuppressant drugs, oncolytic drugs, anti-retroviral |
3 | | drugs, and, on or after July 1, 2014, antipsychotic drugs. On |
4 | | or after July 1, 2014, the Department may exempt children with |
5 | | complex medical needs enrolled in a care coordination entity |
6 | | contracted with the Department to solely coordinate care for |
7 | | such children, if the Department determines that the entity has |
8 | | a comprehensive drug reconciliation program. Drugs prescribed |
9 | | for residents of licensed long-term care facilities as defined |
10 | | in Section 1-113 of the Nursing Home Care Act shall not be |
11 | | subject to prior approval as a result of the 4-prescription |
12 | | limit. |
13 | | (k) No medication therapy management program implemented |
14 | | by the Department shall be contrary to the provisions of the |
15 | | Pharmacy Practice Act. |
16 | | (l) Any provider enrolled with the Department that bills |
17 | | the Department for outpatient drugs and is eligible to enroll |
18 | | in the federal Drug Pricing Program under Section 340B of the |
19 | | federal Public Health Services Act shall enroll in that |
20 | | program. No entity participating in the federal Drug Pricing |
21 | | Program under Section 340B of the federal Public Health |
22 | | Services Act may exclude Medicaid from their participation in |
23 | | that program, although the Department may exclude entities |
24 | | defined in Section 1905(l)(2)(B) of the Social Security Act |
25 | | from this requirement. |
26 | | (Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; |