Full Text of HB4943 102nd General Assembly
HB4943 102ND GENERAL ASSEMBLY
102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
Introduced 1/27/2022, by Rep. Deanne M. Mazzochi
SYNOPSIS AS INTRODUCED:
Amends the Illinois Insurance Code. In provisions concerning pharmacy
benefit manager contracts, provides that if a retail price is to be used by
a pharmacy benefit manager to calculate or estimate a copayment for a drug,
the pharmacy must either report the retail price for the drug and identify
any programs available to retail customers of the pharmacy that an
individual without prescription drug coverage would be eligible for at the
retail pharmacy that could reduce the price of the drug, or reduce the
retail price reported to account for the price reductions that would be
generally or specifically available to the individual without prescription
drug coverage. Changes the definition of "retail price".
A BILL FOR
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AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
The Illinois Insurance Code is amended by
changing Section 513b1 as follows:
(215 ILCS 5/513b1)
Pharmacy benefit manager contracts.
(a) As used in this Section:
"Biological product" has the meaning ascribed to that term
in Section 19.5 of the Pharmacy Practice Act.
"Maximum allowable cost" means the maximum amount that a
pharmacy benefit manager will reimburse a pharmacy for the
cost of a drug.
"Maximum allowable cost list" means a list of drugs for
which a maximum allowable cost has been established by a
pharmacy benefit manager.
"Pharmacy benefit manager" means a person, business, or
entity, including a wholly or partially owned or controlled
subsidiary of a pharmacy benefit manager, that provides claims
processing services or other prescription drug or device
services, or both, for health benefit plans.
"Retail price" means the price
an individual without
prescription drug coverage would pay at a retail pharmacy,
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"Retail price" does not include a pharmacist dispensing fee,
regardless of whether the drug is or is not subject to a
not including a pharmacist dispensing fee
(b) A contract between a health insurer and a pharmacy
benefit manager must require that the pharmacy benefit
(1) Update maximum allowable cost pricing information
at least every 7 calendar days.
(2) Maintain a process that will, in a timely manner,
eliminate drugs from maximum allowable cost lists or
modify drug prices to remain consistent with changes in
pricing data used in formulating maximum allowable cost
prices and product availability.
(3) Provide access to its maximum allowable cost list
to each pharmacy or pharmacy services administrative
organization subject to the maximum allowable cost list.
Access may include a real-time pharmacy website portal to
be able to view the maximum allowable cost list. As used in
this Section, "pharmacy services administrative
organization" means an entity operating within the State
that contracts with independent pharmacies to conduct
business on their behalf with third-party payers. A
pharmacy services administrative organization may provide
administrative services to pharmacies and negotiate and
enter into contracts with third-party payers or pharmacy
benefit managers on behalf of pharmacies.
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(4) Provide a process by which a contracted pharmacy
can appeal the provider's reimbursement for a drug subject
to maximum allowable cost pricing. The appeals process
must, at a minimum, include the following:
(A) A requirement that a contracted pharmacy has
14 calendar days after the applicable fill date to
appeal a maximum allowable cost if the reimbursement
for the drug is less than the net amount that the
network provider paid to the supplier of the drug.
(B) A requirement that a pharmacy benefit manager
must respond to a challenge within 14 calendar days of
the contracted pharmacy making the claim for which the
appeal has been submitted.
(C) A telephone number and e-mail address or
website to network providers, at which the provider
can contact the pharmacy benefit manager to process
and submit an appeal.
(D) A requirement that, if an appeal is denied,
the pharmacy benefit manager must provide the reason
for the denial and the name and the national drug code
number from national or regional wholesalers.
(E) A requirement that, if an appeal is sustained,
the pharmacy benefit manager must make an adjustment
in the drug price effective the date the challenge is
resolved and make the adjustment applicable to all
similarly situated network pharmacy providers, as
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determined by the managed care organization or
pharmacy benefit manager.
(5) Allow a plan sponsor contracting with a pharmacy
benefit manager an annual right to audit compliance with
the terms of the contract by the pharmacy benefit manager,
including, but not limited to, full disclosure of any and
all rebate amounts secured, whether product specific or
generalized rebates, that were provided to the pharmacy
benefit manager by a pharmaceutical manufacturer.
(6) Allow a plan sponsor contracting with a pharmacy
benefit manager to request that the pharmacy benefit
manager disclose the actual amounts paid by the pharmacy
benefit manager to the pharmacy.
(7) Provide notice to the party contracting with the
pharmacy benefit manager of any consideration that the
pharmacy benefit manager receives from the manufacturer
for dispense as written prescriptions once a generic or
biologically similar product becomes available.
(c) In order to place a particular prescription drug on a
maximum allowable cost list, the pharmacy benefit manager
must, at a minimum, ensure that:
(1) if the drug is a generically equivalent drug, it
is listed as therapeutically equivalent and
pharmaceutically equivalent "A" or "B" rated in the United
States Food and Drug Administration's most recent version
of the "Orange Book" or have an NR or NA rating by
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Medi-Span, Gold Standard, or a similar rating by a
nationally recognized reference;
(2) the drug is available for purchase by each
pharmacy in the State from national or regional
wholesalers operating in Illinois; and
(3) the drug is not obsolete.
(d) A pharmacy benefit manager is prohibited from limiting
a pharmacist's ability to disclose whether the cost-sharing
obligation exceeds the retail price for a covered prescription
drug, and the availability of a more affordable alternative
drug, if one is available in accordance with Section 42 of the
Pharmacy Practice Act.
(e) A health insurer or pharmacy benefit manager shall not
require an insured to make a payment for a prescription drug at
the point of sale in an amount that exceeds the lesser of:
(1) the applicable cost-sharing amount; or
(2) the retail price of the drug in the absence of
prescription drug coverage.
(f) This Section applies to contracts entered into or
renewed on or after July 1, 2020.
(g) This Section applies to any group or individual policy
of accident and health insurance or managed care plan that
provides coverage for prescription drugs and that is amended,
delivered, issued, or renewed on or after July 1, 2020.
(h) If a retail price is to be used by a pharmacy benefit
manager to calculate or estimate a copayment for a drug, the
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pharmacy must either:
(1) report the retail price for the drug and identify
any programs available to retail customers of the pharmacy
that an individual without prescription drug coverage
would be eligible for at the retail pharmacy that could
reduce the price of the drug, whether the programs are
specific to the drug or are generally available to
pharmacy customers; or
(2) reduce the retail price reported to account for
the price reductions that would be generally or
specifically available to the individual without
prescription drug coverage, including, but not limited to,
price reductions from senior discounts, volume discounts,
rebate coupons provided by the pharmacy, loyalty rewards,
or discounts earned through the payment of annual fees.
(Source: P.A. 101-452, eff. 1-1-20