HB0152 Enrolled LRB096 02980 RPM 12994 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
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.