Illinois General Assembly - Bill Status for HB0465

Replaces everything after the enacting clause. Amends the Illinois Insurance Code. Provides that a contract between a health insurer and a pharmacy benefit manager must:(1) require the pharmacy benefit manager to update maximum allowable cost pricing information and maintain a process that will eliminate drugs from maximum allowable cost lists or modify drug prices to remain consistent with changes in pricing data; (2) prohibit the pharmacy benefit manager from limiting a pharmacist's ability to disclose the availability of a more affordable alternative drug; and (3) prohibit the pharmacy benefit manager from requiring an insured to make a payment for a prescription drug in an amount that exceeds the lesser of the applicable cost-sharing amount or the retail price of the drug. Contains provisions concerning the inclusion of prescription drugs on a maximum allowable cost list, State licensing requirements for pharmacy benefit managers, and other matters. Makes conforming changes to other Acts. Amends the Managed Care Reform and Patient Rights Act. Provides that a health care plan shall apply any third-party payments for prescription drugs. Makes changes to provisions concerning the denial of coverage for emergency services. Amends the Illinois Public Aid Code. Provides that the Department of Healthcare and Family Services may enter into a contract with any third party on a fee-for-service reimbursement model for the purpose of administering pharmacy benefits. Requires the Department to ensure coordination of care between the third-party administrator and managed care organizations as a consideration in any contracts established. Amends the Freedom of Information Act to exempt from disclosure certain information pharmacy benefits managers are required to provide under the Illinois Public Aid Code. Contains a severability provision.

Replaces everything after the enacting clause. Reinserts the provisions of House Amendment No. 1, but with the following changes: Further amends the Illinois Insurance Code. In a provision concerning contracts between health insurers and pharmacy benefit managers, provides that such contracts must require pharmacy benefit managers to: (1) update maximum allowable cost pricing information at least every 7 calendar days; (2) provide access to its maximum allowable cost list to each pharmacy or pharmacy services administrative organization, as defined, subject to the maximum allowable cost list; (4) provide a process by which a contracted pharmacy can appeal the provider's reimbursement for a drug subject to maximum allowable cost pricing; and other matters. Regarding a drug on the maximum allowable cost list, requires pharmacy benefits managers to ensure that: (i) if a drug is a generically equivalent drug, it is listed as therapeutically equivalent and pharmaceutically equivalent to certain rating standards; (ii) the drug is available for purchase by each pharmacy in the State from national or regional wholesalers operating in Illinois; and (ii) the drug is not obsolete (rather than requiring a drug to have at least 3 or more nationally available, therapeutically equivalent, multiple source generic drugs with a significant cost difference and be available for purchase without limitations by all pharmacies in the State from national or regional wholesalers). Permits the Director of Insurance to examine a pharmacy benefit manager's designee, representative, or other specified persons (rather than any individual) about the business of the pharmacy benefit manager. Contains provisions concerning the denial of a pharmacy benefits manager's registration application or the suspension or revocation of a pharmacy benefits manager's registration. Defines terms. Further amends the Managed Care Reform and Patient Rights Act. Makes changes to the definition of "emergency medical condition". Removes changes made to a provision concerning the denial of coverage and payment for emergency services provided without prior authorization or an approved plan. Further amends the Illinois Public Aid Code. Makes changes to certain reporting requirements imposed on the Director of Healthcare and Family Services. Requires a pharmacy benefit manager to make certain disclosures to the Department of Healthcare and Family Services upon request. Requires a pharmacy benefit manager to make certain written disclosures to a pharmacy provider or pharmacy services administrative organization. Defines "pharmacy services administrative organization." Requires the Department to adopt rules establishing reasonable dispensing fees for fee-for-service payments in accordance with guidance or guidelines from the federal Centers for Medicare and Medicaid Services.

×