Full Text of HB4707 103rd General Assembly
HB4707 103RD GENERAL ASSEMBLY | | | 103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024 HB4707 Introduced 2/6/2024, by Rep. Hoan Huynh SYNOPSIS AS INTRODUCED: | | 305 ILCS 5/5-5.12 | from Ch. 23, par. 5-5.12 |
| Amends the Medical Assistance Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to impose a 4-prescription drug limit and prior authorization requirement under the medical assistance program. |
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| | A BILL FOR |
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| 1 | | AN ACT concerning public aid. | 2 | | Be it enacted by the People of the State of Illinois, | 3 | | represented in the General Assembly: | 4 | | Section 5. The Illinois Public Aid Code is amended by | 5 | | changing Section 5-5.12 as follows: | 6 | | (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12) | 7 | | Sec. 5-5.12. Pharmacy payments. | 8 | | (a) Every request submitted by a pharmacy for | 9 | | reimbursement under this Article for prescription drugs | 10 | | provided to a recipient of aid under this Article shall | 11 | | include the name of the prescriber or an acceptable | 12 | | identification number as established by the Department. | 13 | | (b) Pharmacies providing prescription drugs under this | 14 | | Article shall be reimbursed at a rate which shall include a | 15 | | professional dispensing fee as determined by the Illinois | 16 | | Department, plus the current acquisition cost of the | 17 | | prescription drug dispensed. The Illinois Department shall | 18 | | update its information on the acquisition costs of all | 19 | | prescription drugs no less frequently than every 30 days. | 20 | | However, the Illinois Department may set the rate of | 21 | | reimbursement for the acquisition cost, by rule, at a | 22 | | percentage of the current average wholesale acquisition cost. | 23 | | (c) (Blank). |
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| 1 | | (d) The Department shall review utilization of narcotic | 2 | | medications in the medical assistance program and impose | 3 | | utilization controls that protect against abuse. | 4 | | (e) When making determinations as to which drugs shall be | 5 | | on a prior approval list, the Department shall include as part | 6 | | of the analysis for this determination, the degree to which a | 7 | | drug may affect individuals in different ways based on factors | 8 | | including the gender of the person taking the medication. | 9 | | (f) The Department shall cooperate with the Department of | 10 | | Public Health and the Department of Human Services Division of | 11 | | Mental Health in identifying psychotropic medications that, | 12 | | when given in a particular form, manner, duration, or | 13 | | frequency (including "as needed") in a dosage, or in | 14 | | conjunction with other psychotropic medications to a nursing | 15 | | home resident or to a resident of a facility licensed under the | 16 | | ID/DD Community Care Act or the MC/DD Act, may constitute a | 17 | | chemical restraint or an "unnecessary drug" as defined by the | 18 | | Nursing Home Care Act or Titles XVIII and XIX of the Social | 19 | | Security Act and the implementing rules and regulations. The | 20 | | Department shall require prior approval for any such | 21 | | medication prescribed for a nursing home resident or to a | 22 | | resident of a facility licensed under the ID/DD Community Care | 23 | | Act or the MC/DD Act, that appears to be a chemical restraint | 24 | | or an unnecessary drug. The Department shall consult with the | 25 | | Department of Human Services Division of Mental Health in | 26 | | developing a protocol and criteria for deciding whether to |
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| 1 | | grant such prior approval. | 2 | | (g) The Department may by rule provide for reimbursement | 3 | | of the dispensing of a 90-day supply of a generic or brand | 4 | | name, non-narcotic maintenance medication in circumstances | 5 | | where it is cost effective. | 6 | | (g-5) On and after July 1, 2012, the Department may | 7 | | require the dispensing of drugs to nursing home residents be | 8 | | in a 7-day supply or other amount less than a 31-day supply. | 9 | | The Department shall pay only one dispensing fee per 31-day | 10 | | supply. | 11 | | (h) Effective July 1, 2011, the Department shall | 12 | | discontinue coverage of select over-the-counter drugs, | 13 | | including analgesics and cough and cold and allergy | 14 | | medications. | 15 | | (h-5) On and after July 1, 2012, the Department shall | 16 | | impose utilization controls, including, but not limited to, | 17 | | prior approval on specialty drugs, oncolytic drugs, drugs for | 18 | | the treatment of HIV or AIDS, immunosuppressant drugs, and | 19 | | biological products in order to maximize savings on these | 20 | | drugs. The Department may adjust payment methodologies for | 21 | | non-pharmacy billed drugs in order to incentivize the | 22 | | selection of lower-cost drugs. For drugs for the treatment of | 23 | | AIDS, the Department shall take into consideration the | 24 | | potential for non-adherence by certain populations, and shall | 25 | | develop protocols with organizations or providers primarily | 26 | | serving those with HIV/AIDS, as long as such measures intend |
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| 1 | | to maintain cost neutrality with other utilization management | 2 | | controls such as prior approval. For hemophilia, the | 3 | | Department shall develop a program of utilization review and | 4 | | control which may include, in the discretion of the | 5 | | Department, prior approvals. The Department may impose special | 6 | | standards on providers that dispense blood factors which shall | 7 | | include, in the discretion of the Department, staff training | 8 | | and education; patient outreach and education; case | 9 | | management; in-home patient assessments; assay management; | 10 | | maintenance of stock; emergency dispensing timeframes; data | 11 | | collection and reporting; dispensing of supplies related to | 12 | | blood factor infusions; cold chain management and packaging | 13 | | practices; care coordination; product recalls; and emergency | 14 | | clinical consultation. The Department may require patients to | 15 | | receive a comprehensive examination annually at an appropriate | 16 | | provider in order to be eligible to continue to receive blood | 17 | | factor. | 18 | | (i) On and after July 1, 2012, the Department shall reduce | 19 | | any rate of reimbursement for services or other payments or | 20 | | alter any methodologies authorized by this Code to reduce any | 21 | | rate of reimbursement for services or other payments in | 22 | | accordance with Section 5-5e. | 23 | | (j) (Blank). On and after July 1, 2012, the Department | 24 | | shall impose limitations on prescription drugs such that the | 25 | | Department shall not provide reimbursement for more than 4 | 26 | | prescriptions, including 3 brand name prescriptions, for |
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| 1 | | distinct drugs in a 30-day period, unless prior approval is | 2 | | received for all prescriptions in excess of the 4-prescription | 3 | | limit. Drugs in the following therapeutic classes shall not be | 4 | | subject to prior approval as a result of the 4-prescription | 5 | | limit: immunosuppressant drugs, oncolytic drugs, | 6 | | anti-retroviral drugs, and, on or after July 1, 2014, | 7 | | antipsychotic drugs. On or after July 1, 2014, the Department | 8 | | may exempt children with complex medical needs enrolled in a | 9 | | care coordination entity contracted with the Department to | 10 | | solely coordinate care for such children, if the Department | 11 | | determines that the entity has a comprehensive drug | 12 | | reconciliation program. | 13 | | (k) No medication therapy management program implemented | 14 | | by the Department shall be contrary to the provisions of the | 15 | | Pharmacy Practice Act. | 16 | | (l) Any provider enrolled with the Department that bills | 17 | | the Department for outpatient drugs and is eligible to enroll | 18 | | in the federal Drug Pricing Program under Section 340B of the | 19 | | federal Public Health Service Act shall enroll in that | 20 | | program. No entity participating in the federal Drug Pricing | 21 | | Program under Section 340B of the federal Public Health | 22 | | Service Act may exclude fee-for-service Medicaid from their | 23 | | participation in that program, however, entities defined in | 24 | | Section 1905(l)(2)(B) of the Social Security Act are excluded | 25 | | from this requirement. This subsection does not apply to | 26 | | outpatient drugs billed to Medicaid managed care |
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| 1 | | organizations. | 2 | | (Source: P.A. 102-558, eff. 8-20-21; 102-778, eff. 7-1-22.) |
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