102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB1589

 

Introduced 2/26/2021, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.43 new
215 ILCS 134/25
225 ILCS 85/26

    Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall provide coverage for anti-epileptic drugs. Provides that coverage for anti-epileptic drugs may not impose a waiting period or any deductible, coinsurance, copayment, or other cost-sharing limitation. Defines "anti-epileptic drug", "epilepsy", and "seizure". Amends the Managed Care Reform and Patient Rights Act. Provides that anti-seizure prescription drugs may not be substituted with a generic drug under provisions of the Pharmacy Practice Act under which a pharmacist may substitute a therapeutically equivalent generic drug for a prescription drug. Amends the Pharmacy Practice Act. Provides that a pharmacist may not interchange an anti-epileptic drug or formulation of an anti-epileptic drug for the treatment of epilepsy. Provides that a prescribing physician shall document that such anti-epileptic drug or formulation of an anti-epileptic drug for the treatment of epilepsy is clinically necessary for the patient's optimal care. Removes provisions concerning notification and consent required when a physician substitutes a generic prescription in place of a brand-name anti-epileptic drug.


LRB102 13155 BMS 18498 b

 

 

A BILL FOR

 

SB1589LRB102 13155 BMS 18498 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5adding Section 356z.43 as follows:
 
6    (215 ILCS 5/356z.43 new)
7    Sec. 356z.43. Coverage of anti-seizure prescription drugs.
8    (a) The General Assembly finds that this Section is
9necessary for the immediate preservation of public peace,
10health, and safety.
11    (b) In this Section:
12    "Anti-epileptic drug" means (i) a drug prescribed for the
13treatment of epilepsy or (ii) a drug used to treat or prevent
14seizures.
15    "Epilepsy" means a neurological condition characterized by
16recurrent seizures.
17    "Seizure" means a brief disturbance in the electrical
18activity of the brain.
19    (c) An individual or group policy of accident and health
20insurance amended, delivered, issued, or renewed in this State
21after the effective date of this amendatory Act of the 102nd
22General Assembly shall provide coverage for anti-epileptic
23drugs.

 

 

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1    (d) Coverage required under this Section may not impose a
2waiting period or any deductible, coinsurance, copayment, or
3other cost-sharing limitation that is greater than that
4required for other coverage under the policy.
 
5    Section 10. The Managed Care Reform and Patient Rights Act
6is amended by changing Section 25 as follows:
 
7    (215 ILCS 134/25)
8    Sec. 25. Transition of services.
9    (a) A health care plan shall provide for continuity of
10care for its enrollees as follows:
11        (1) If an enrollee's physician leaves the health care
12    plan's network of health care providers for reasons other
13    than termination of a contract in situations involving
14    imminent harm to a patient or a final disciplinary action
15    by a State licensing board and the physician remains
16    within the health care plan's service area, the health
17    care plan shall permit the enrollee to continue an ongoing
18    course of treatment with that physician during a
19    transitional period:
20            (A) of 90 days from the date of the notice of
21        physician's termination from the health care plan to
22        the enrollee of the physician's disaffiliation from
23        the health care plan if the enrollee has an ongoing
24        course of treatment; or

 

 

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1            (B) if the enrollee has entered the third
2        trimester of pregnancy at the time of the physician's
3        disaffiliation, that includes the provision of
4        post-partum care directly related to the delivery.
5        (2) Notwithstanding the provisions in item (1) of this
6    subsection, such care shall be authorized by the health
7    care plan during the transitional period only if the
8    physician agrees:
9            (A) to continue to accept reimbursement from the
10        health care plan at the rates applicable prior to the
11        start of the transitional period;
12            (B) to adhere to the health care plan's quality
13        assurance requirements and to provide to the health
14        care plan necessary medical information related to
15        such care; and
16            (C) to otherwise adhere to the health care plan's
17        policies and procedures, including but not limited to
18        procedures regarding referrals and obtaining
19        preauthorizations for treatment.
20        (3) During an enrollee's plan year, a health care plan
21    shall not remove a drug from its formulary or negatively
22    change its preferred or cost-tier sharing unless, at least
23    60 days before making the formulary change, the health
24    care plan:
25            (A) provides general notification of the change in
26        its formulary to current and prospective enrollees;

 

 

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1            (B) directly notifies enrollees currently
2        receiving coverage for the drug, including information
3        on the specific drugs involved and the steps they may
4        take to request coverage determinations and
5        exceptions, including a statement that a certification
6        of medical necessity by the enrollee's prescribing
7        provider will result in continuation of coverage at
8        the existing level; and
9            (C) directly notifies by first class mail and
10        through an electronic transmission, if available, the
11        prescribing provider of all health care plan enrollees
12        currently prescribed the drug affected by the proposed
13        change; the notice shall include a one-page form by
14        which the prescribing provider can notify the health
15        care plan by first class mail that coverage of the drug
16        for the enrollee is medically necessary.
17        The notification in paragraph (C) may direct the
18    prescribing provider to an electronic portal through which
19    the prescribing provider may electronically file a
20    certification to the health care plan that coverage of the
21    drug for the enrollee is medically necessary. The
22    prescribing provider may make a secure electronic
23    signature beside the words "certification of medical
24    necessity", and this certification shall authorize
25    continuation of coverage for the drug.
26        If the prescribing provider certifies to the health

 

 

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1    care plan either in writing or electronically that the
2    drug is medically necessary for the enrollee as provided
3    in paragraph (C), a health care plan shall authorize
4    coverage for the drug prescribed based solely on the
5    prescribing provider's assertion that coverage is
6    medically necessary, and the health care plan is
7    prohibited from making modifications to the coverage
8    related to the covered drug, including, but not limited
9    to:
10            (i) increasing the out-of-pocket costs for the
11        covered drug;
12            (ii) moving the covered drug to a more restrictive
13        tier; or
14            (iii) denying an enrollee coverage of the drug for
15        which the enrollee has been previously approved for
16        coverage by the health care plan.
17        Nothing in this item (3) prevents a health care plan
18    from removing a drug from its formulary or denying an
19    enrollee coverage if the United States Food and Drug
20    Administration has issued a statement about the drug that
21    calls into question the clinical safety of the drug, the
22    drug manufacturer has notified the United States Food and
23    Drug Administration of a manufacturing discontinuance or
24    potential discontinuance of the drug as required by
25    Section 506C of the Federal Food, Drug, and Cosmetic Act,
26    as codified in 21 U.S.C. 356c, or the drug manufacturer

 

 

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1    has removed the drug from the market.
2        Nothing in this item (3) prohibits a health care plan,
3    by contract, written policy or procedure, or any other
4    agreement or course of conduct, from requiring a
5    pharmacist to effect substitutions of prescription drugs
6    consistent with Section 19.5 of the Pharmacy Practice Act,
7    under which a pharmacist may substitute an interchangeable
8    biologic for a prescribed biologic product, and Section 25
9    of the Pharmacy Practice Act, under which a pharmacist may
10    select a generic drug determined to be therapeutically
11    equivalent by the United States Food and Drug
12    Administration and in accordance with the Illinois Food,
13    Drug and Cosmetic Act, with the exception of anti-seizure
14    prescription drugs, which may not be substituted with a
15    generic drug.
16        This item (3) applies to a policy or contract that is
17    amended, delivered, issued, or renewed on or after January
18    1, 2019. This item (3) does not apply to a health plan as
19    defined in the State Employees Group Insurance Act of 1971
20    or medical assistance under Article V of the Illinois
21    Public Aid Code.
22    (b) A health care plan shall provide for continuity of
23care for new enrollees as follows:
24        (1) If a new enrollee whose physician is not a member
25    of the health care plan's provider network, but is within
26    the health care plan's service area, enrolls in the health

 

 

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1    care plan, the health care plan shall permit the enrollee
2    to continue an ongoing course of treatment with the
3    enrollee's current physician during a transitional period:
4            (A) of 90 days from the effective date of
5        enrollment if the enrollee has an ongoing course of
6        treatment; or
7            (B) if the enrollee has entered the third
8        trimester of pregnancy at the effective date of
9        enrollment, that includes the provision of post-partum
10        care directly related to the delivery.
11        (2) If an enrollee elects to continue to receive care
12    from such physician pursuant to item (1) of this
13    subsection, such care shall be authorized by the health
14    care plan for the transitional period only if the
15    physician agrees:
16            (A) to accept reimbursement from the health care
17        plan at rates established by the health care plan;
18        such rates shall be the level of reimbursement
19        applicable to similar physicians within the health
20        care plan for such services;
21            (B) to adhere to the health care plan's quality
22        assurance requirements and to provide to the health
23        care plan necessary medical information related to
24        such care; and
25            (C) to otherwise adhere to the health care plan's
26        policies and procedures including, but not limited to

 

 

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1        procedures regarding referrals and obtaining
2        preauthorization for treatment.
3    (c) In no event shall this Section be construed to require
4a health care plan to provide coverage for benefits not
5otherwise covered or to diminish or impair preexisting
6condition limitations contained in the enrollee's contract. In
7no event shall this Section be construed to prohibit the
8addition of prescription drugs to a health care plan's list of
9covered drugs during the coverage year.
10(Source: P.A. 100-1052, eff. 8-24-18.)
 
11    Section 15. The Pharmacy Practice Act is amended by
12changing Section 26 as follows:
 
13    (225 ILCS 85/26)
14    (Section scheduled to be repealed on January 1, 2023)
15    Sec. 26. Anti-epileptic drug product selection prohibited.
16    (a) The General Assembly finds that this Section is
17necessary for the immediate preservation of the public peace,
18health, and safety.
19    (b) In this Section:
20    "Anti-epileptic drug" means (i) any drug prescribed for
21the treatment of epilepsy or (ii) a drug used to treat or
22prevent seizures.
23    "Epilepsy" means a neurological condition characterized by
24recurrent seizures.

 

 

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1    "Seizure" means a brief disturbance in the electrical
2activity of the brain.
3    (c) A When the prescribing physician has indicated on the
4original prescription "may not substitute", a pharmacist may
5not interchange an anti-epileptic drug or formulation of an
6anti-epileptic drug for the treatment of epilepsy. The
7prescribing physician shall document that such anti-epileptic
8drug or formulation of an anti-epileptic drug for the
9treatment of epilepsy is clinically necessary for the
10patient's optimal care without notification and the documented
11consent of the prescribing physician and the patient or the
12patient's parent, legal guardian, or spouse. This Section does
13not apply to medication orders issued for anti-epileptic drugs
14for any in-patient care in a licensed hospital.
15    (d) (Blank). If a pharmacist substitutes any generic
16prescription in place of a brand-name anti-epileptic drug,
17then the pharmacist shall provide written notice to the
18patient no later than the time the prescription is dispensed.
19(Source: P.A. 97-456, eff. 1-1-12.)