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1 | AN ACT concerning regulation.
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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 Insurance Code is amended by adding | |||||||||||||||||||
5 | Section 356z.23 as follows: | |||||||||||||||||||
6 | (215 ILCS 5/356z.23 new) | |||||||||||||||||||
7 | Sec. 356z.23. Specialty tier prescription coverage. | |||||||||||||||||||
8 | (a) As used in this Section: | |||||||||||||||||||
9 | "Coinsurance" means a cost-sharing amount set as a | |||||||||||||||||||
10 | percentage of the total cost of a drug. | |||||||||||||||||||
11 | "Copayment" means a cost-sharing amount set as a dollar | |||||||||||||||||||
12 | value. | |||||||||||||||||||
13 | "Non-preferred drug" means a drug in a tier designed for | |||||||||||||||||||
14 | certain drugs deemed non-preferred and therefore subject to | |||||||||||||||||||
15 | higher cost-sharing amounts than preferred drugs. | |||||||||||||||||||
16 | "Preferred drug" means a drug in a tier designed for | |||||||||||||||||||
17 | certain drugs deemed preferred and therefore subject to lower | |||||||||||||||||||
18 | cost-sharing amounts than non-preferred drugs. | |||||||||||||||||||
19 | "Tiered formulary" means a formulary that provides | |||||||||||||||||||
20 | coverage for prescription drugs as part of a policy of health | |||||||||||||||||||
21 | and accident insurance for which cost sharing, deductibles, or | |||||||||||||||||||
22 | coinsurance obligations are determined by category or tier of | |||||||||||||||||||
23 | prescription drugs and includes at least 2 different tiers. |
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1 | (b) On or after the effective date of this amendatory Act | ||||||
2 | of the 99th General Assembly, every insurer that amends, | ||||||
3 | delivers, issues, or renews individual and group accident and | ||||||
4 | health policies providing coverage for prescription drugs | ||||||
5 | shall ensure that: | ||||||
6 | (1) for insurance plans rated platinum, gold, and | ||||||
7 | silver level, as defined in 45 CFR 156.140, and regardless | ||||||
8 | of whether or not the plan was acquired through an exchange | ||||||
9 | authorized under the federal Patient Protection and | ||||||
10 | Affordable Care Act, any required copayment or coinsurance | ||||||
11 | applicable to drugs does not exceed $100 per month for up | ||||||
12 | to a 30-day supply of any single drug; and | ||||||
13 | (2) for bronze plans, as defined in 45 CFR 156.140, and | ||||||
14 | regardless of whether or not the plan was acquired through | ||||||
15 | an exchange authorized under the federal Patient | ||||||
16 | Protection and Affordable Care Act, any required copayment | ||||||
17 | or coinsurance applicable to drugs does not exceed $200 per | ||||||
18 | month for up to a 30-day supply of any single drug. | ||||||
19 | (c) The limits described in subsection (b) of this Section | ||||||
20 | shall be inclusive of any patient out-of-pocket spending, | ||||||
21 | including payments towards any deductibles, copayments, or | ||||||
22 | coinsurance and shall be applicable before any applicable | ||||||
23 | deductible is reached. | ||||||
24 | (d) An insurance plan that meets the requirements for a | ||||||
25 | catastrophic plan, as defined in 45 CFR 156.155(a), shall be | ||||||
26 | exempt from the requirements of subsection (b) of this Section. |
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1 | (e) Subject to subsection (f) of this Section, the limits | ||||||
2 | in subsection (b) of this Section shall apply at any point in | ||||||
3 | the benefit design, including before any after any applicable | ||||||
4 | deductible is reached. | ||||||
5 | (f) For any enrollee that is enrolled in a policy that, but | ||||||
6 | for the requirements of subsection (b) of this Section, would | ||||||
7 | be a high deductible health plan as defined in Section | ||||||
8 | 223(c)(2)(A) of the Internal Revenue Code of 1986, the limits | ||||||
9 | described in subsection (b) of this Section shall be applicable | ||||||
10 | only after the minimum annual deductible specified in Section | ||||||
11 | 223(c)(2)(A) of the Internal Revenue Code of 1986 is reached. | ||||||
12 | (g) An insurer that issues policies of accident and health | ||||||
13 | insurance that provides coverage for prescription drugs shall | ||||||
14 | implement an exceptions process that allows enrollees to | ||||||
15 | request an exception to the formulary. An insurer may use its | ||||||
16 | existing medical exceptions process to satisfy this | ||||||
17 | requirement. Under such an exception, a non-formulary drug | ||||||
18 | shall be deemed covered under the formulary if the prescribing | ||||||
19 | physician determines that the formulary drug for treatment of | ||||||
20 | the same condition either would not be as effective for the | ||||||
21 | individual, or would have adverse effects for the individual, | ||||||
22 | or both. If an enrollee is denied an exception, the denial | ||||||
23 | shall be considered an adverse coverage determination and will | ||||||
24 | be subject to the health plan internal and external review | ||||||
25 | processes. | ||||||
26 | (h) On or after the effective date of this amendatory Act |
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1 | of the 99th General Assembly, every insurer that amends, | ||||||
2 | delivers, issues, or renews individual and group accident and | ||||||
3 | health policies providing coverage for prescription drugs | ||||||
4 | shall ensure that beneficiary's annual out-of-pocket | ||||||
5 | expenditures for prescription drugs are limited to no more than | ||||||
6 | 50% of the dollar amounts in effect under Section 1302(c)(1) of | ||||||
7 | the federal Patient Protection and Affordable Care Act for | ||||||
8 | self-only and family coverage, respectively. | ||||||
9 | (i) An insurer that issues policies of accident and health | ||||||
10 | policies that provides coverage for prescription drugs and uses | ||||||
11 | a tiered formulary shall implement an exceptions process that | ||||||
12 | allows enrollees to request an exception to the tiered | ||||||
13 | cost-sharing structure. Under an exception, a non-preferred | ||||||
14 | drug may be covered under the cost sharing applicable for | ||||||
15 | preferred drugs if the prescribing health care provider | ||||||
16 | determines that the preferred drug for treatment of the same | ||||||
17 | condition either would not be as effective for the individual, | ||||||
18 | would have adverse effects for the individual, or both. If an | ||||||
19 | enrollee is denied a cost-sharing exception, the denial shall | ||||||
20 | be considered an adverse event and shall be subject to the | ||||||
21 | health plan's internal review process. | ||||||
22 | (j) Nothing in this Section shall be construed to require | ||||||
23 | an insurer that issues accident and health policies: | ||||||
24 | (1) provide coverage for any additional drugs not | ||||||
25 | otherwise required by law; | ||||||
26 | (2) implement specific utilization management |
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1 | techniques, such as prior authorization or step therapy; or | ||||||
2 | (3) cease utilization of tiered cost-sharing | ||||||
3 | structures, including those strategies used to incentivize | ||||||
4 | use of preventive services, disease management, and | ||||||
5 | low-cost treatment options. | ||||||
6 | (k) Nothing in this Section shall be construed to require a | ||||||
7 | pharmacist to substitute a drug without the consent of the | ||||||
8 | prescribing physician. | ||||||
9 | (l) The Director shall adopt rules outlining the | ||||||
10 | enforcement processes for this Section.
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11 | Section 99. Effective date. This Act takes effect January | ||||||
12 | 1, 2016.
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