98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB2585

 

Introduced 5/29/2013, by Sen. Dan Kotowski - Mattie Hunter

 

SYNOPSIS AS INTRODUCED:
 
See Index

    Amends the Illinois Public Aid Code and the Illinois Insurance Code. Requires the Department of Healthcare and Family Services and the Department of Insurance to jointly develop a uniform prior authorization form for prescription drug benefits on or before July 1, 2014. Provides that 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. Provides that on and after January 1, 2015, a health insurer that provides prescription drug benefits shall utilize and accept the prior authorization form when requiring prior authorization for prescription drug benefits; and that 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, the prior authorization request shall be deemed to have been granted. Exempts certain providers. Sets forth certain criteria for the prior authorization form. Provides that "prescribing provider" includes a provider authorized to write a prescription as described in the Pharmacy Practice Act. Effective January 1, 2014.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

SB2585LRB098 12068 KTG 45784 b

1    AN ACT concerning public aid.
 
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 adding
5Section 364.3 as follows:
 
6    (215 ILCS 5/364.3 new)
7    Sec. 364.3. Uniform prior authorization form; prescription
8benefits.
9    (a) Notwithstanding any other provision of law, on and
10after January 1, 2015, a health insurer that provides
11prescription drug benefits shall utilize and accept the prior
12authorization form developed pursuant to subsection (c) when
13requiring prior authorization for prescription drug benefits.
14    (b) If a health insurer fails to utilize or accept the
15prior authorization form, or fails to respond within 2 business
16days upon receipt of a completed prior authorization request
17from a prescribing provider, pursuant to the submission of the
18prior authorization form developed as described in subsection
19(c), the prior authorization request shall be deemed to have
20been granted.
21    (c) On or before July 1, 2014, the Department and the
22Department of Healthcare and Family Services shall jointly
23develop a uniform prior authorization form. Notwithstanding

 

 

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1any other provision of law, on and after January 1, 2015, or 6
2months after the form is developed, whichever is later, every
3prescribing provider may use that uniform prior authorization
4form to request prior authorization for coverage of
5prescription drug benefits and every health insurer shall
6accept that form as sufficient to request prior authorization
7for prescription drug benefits.
8    (d) The prior authorization form developed pursuant to
9subsection (c) shall meet the following criteria:
10        (1) The form shall not exceed 2 pages.
11        (2) The form shall be made electronically available by
12    the Department and the health insurer.
13        (3) The completed form may also be electronically
14    submitted from the prescribing provider to the health
15    insurer.
16        (4) The Department and the Department of Healthcare and
17    Family Services shall develop the form with input from
18    interested parties from at least one public meeting.
19        (5) The Department and the Department of Healthcare and
20    Family Services, in development of the standardized form,
21    shall take into consideration the following:
22            (A) Existing prior authorization forms established
23        by the federal Centers for Medicare and Medicaid
24        Services and the Department of Healthcare and Family
25        Services.
26            (B) National standards pertaining to electronic

 

 

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1        prior authorization.
2    (e) For purposes of this Section, "prescribing provider"
3includes a provider authorized to write a prescription, as
4described in subsection (e) of Section 3 of the Pharmacy
5Practice Act, to treat a medical condition of an insured.
 
6    Section 10. The Illinois Public Aid Code is amended by
7adding Section 5-5.12b as follows:
 
8    (305 ILCS 5/5-5.12b new)
9    Sec. 5-5.12b. Uniform prior authorization form;
10prescription benefits.
11    (a) Notwithstanding any other provision of law, on and
12after January 1, 2015, a health care service plan that provides
13prescription drug benefits shall utilize and accept the prior
14authorization form developed pursuant to subsection (c) when
15requiring prior authorization for prescription drug benefits.
16This Section does not apply in the event that a physician or
17physician group has been delegated the financial risk for
18prescription drugs by a health care service plan and does not
19use a prior authorization process. This Section does not apply
20to a health care service plan, or to its affiliated providers,
21if the health care service plan owns and operates its
22pharmacies and does not use a prior authorization process for
23prescription drugs.
24    (b) If a health care service plan fails to utilize or

 

 

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1accept the prior authorization form, or fails to respond within
22 business days upon receipt of a completed prior authorization
3request from a prescribing provider, pursuant to the submission
4of the prior authorization form developed as described in
5subsection (c), the prior authorization request shall be deemed
6to have been granted.
7    (c) On or before July 1, 2014, the Department and the
8Department of Insurance shall jointly develop a uniform prior
9authorization form. Notwithstanding any other provision of
10law, on and after January 1, 2015, or 6 months after the form
11is developed, whichever is later, every prescribing provider
12may use that uniform prior authorization form to request prior
13authorization for coverage of prescription drug benefits and
14every health care service plan shall accept that form as
15sufficient to request prior authorization for prescription
16drug benefits.
17    (d) The prior authorization form developed pursuant to
18subsection (c) shall meet the following criteria:
19        (1) The form shall not exceed 2 pages.
20        (2) The form shall be made electronically available by
21    the Department and the health care service plan.
22        (3) The completed form may also be electronically
23    submitted from the prescribing provider to the health care
24    service plan.
25        (4) The Department and the Department of Insurance
26    shall develop the form with input from interested parties

 

 

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1    from at least one public meeting.
2        (5) The Department and the Department of Insurance, in
3    development of the standardized form, shall take into
4    consideration the following:
5            (A) Existing prior authorization forms established
6        by the federal Centers for Medicare and Medicaid
7        Services and the Department.
8            (B) National standards pertaining to electronic
9        prior authorization.
10    (e) For purposes of this Section, "prescribing provider"
11includes a provider authorized to write a prescription, as
12described in subsection (e) of Section 3 of the Pharmacy
13Practice Act, to treat a medical condition of an enrollee.
 
14    Section 99. Effective date. This Act takes effect January
151, 2014.

 

 

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1 INDEX
2 Statutes amended in order of appearance
3    215 ILCS 5/364.3 new
4    305 ILCS 5/5-5.12b new