Full Text of SB2222 95th General Assembly
SB2222sam004 95TH GENERAL ASSEMBLY
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Sen. John J. Cullerton
Filed: 4/3/2008
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09500SB2222sam004 |
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LRB095 18675 RAS 48829 a |
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| AMENDMENT TO SENATE BILL 2222
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| AMENDMENT NO. ______. Amend Senate Bill 2222, AS AMENDED, | 3 |
| by replacing everything after the enacting clause with the | 4 |
| following: | 5 |
| "Section 5. The Illinois Insurance Code is amended by | 6 |
| changing the heading of Article XXXI 1/2 and Sections 512-1, | 7 |
| 512-2, 512-3, 512-4, 512-5, 512-6, 512-7, 512-8, 512-9, and | 8 |
| 512-10 and by adding Sections 512-7.5, 512-7.10, 512-11, | 9 |
| 512-12, and 512-13 as follows: | 10 |
| (215 ILCS 5/Art. XXXI.5 heading) | 11 |
| ARTICLE XXXI 1/2.
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| PHARMACEUTICAL BENEFITS MANAGEMENT
THIRD PARTY PRESCRIPTION
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| PROGRAMS
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| (215 ILCS 5/512-1) (from Ch. 73, par. 1065.59-1)
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| Sec. 512-1. Short Title. This Article shall be known and |
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| may be cited
as the " Pharmaceutical Benefits Management | 2 |
| Programs Law
Third Party Prescription Program Act ".
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| (Source: P.A. 82-1005.)
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| (215 ILCS 5/512-2) (from Ch. 73, par. 1065.59-2)
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| Sec. 512-2. Purpose. It is hereby determined and declared | 6 |
| that the
purpose of this Article is to regulate pharmaceutical | 7 |
| benefits management programs
certain practices engaged in by | 8 |
| third-party
prescription
program administrators .
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| (Source: P.A. 82-1005.)
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| (215 ILCS 5/512-3) (from Ch. 73, par. 1065.59-3)
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| Sec. 512-3. Definitions. For the purposes of this Article, | 12 |
| unless the
context otherwise requires, the terms defined in | 13 |
| this Article have the meanings
ascribed
to them herein:
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| "Covered entity" means any entity that has entered into an | 15 |
| agreement, directly or indirectly, with a pharmaceutical | 16 |
| benefits manager to provide a pharmaceutical benefits | 17 |
| management program. "Covered entity" includes, but is not | 18 |
| limited to, a person or entity that has entered into a group | 19 |
| contract for health care services with an insurer, Health | 20 |
| Maintenance Organization, Limited Health Services Organization | 21 |
| or Voluntary Health Services Plan under which the | 22 |
| pharmaceutical benefits manager is contractually obligated to | 23 |
| provide a pharmaceutical benefits management program. | 24 |
| "Covered individual" means a member, participant, |
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| enrollee, contract holder, policy holder, or beneficiary of a | 2 |
| covered entity who is provided health coverage by the covered | 3 |
| entity. "Covered individual" includes, but is not limited to, a | 4 |
| dependent or other person who is provided health coverage | 5 |
| though a policy, contract, or plan for a covered individual. | 6 |
| "Director" means the Director of the Division of Insurance | 7 |
| of the Department of Financial and Professional Regulation. | 8 |
| "Division" means the Division of Insurance of the | 9 |
| Department of Financial and Professional Regulation. | 10 |
| "Maximum allowable cost" or "MAC" means the maximum per | 11 |
| unit reimbursement as established and determined by the | 12 |
| pharmaceutical benefits manager for a drug, medical product, or | 13 |
| device at the time a claim is processed. | 14 |
| "Pharmaceutical benefits management program" or "program" | 15 |
| means any system established by contract or otherwise of (i) | 16 |
| providing for the administration of or reimbursement for | 17 |
| pharmaceutical services and prescription drug products offered | 18 |
| or operated in this State by a PBM for or on behalf of a covered | 19 |
| entity or
(ii) procuring prescription drugs at a negotiated | 20 |
| rate for dispensation to covered individuals by a | 21 |
| pharmaceutical benefits manager operating in this State. | 22 |
| "Pharmaceutical benefits manager " or " PBM" means any | 23 |
| person, partnership, or corporation that issues or causes to be | 24 |
| issued any payment or reimbursement to a provider for services | 25 |
| rendered pursuant to a pharmaceutical benefits management | 26 |
| program or an entity that procures prescription drugs at a |
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| negotiated rate. "Pharmaceutical benefits manager " or " PBM" | 2 |
| does not include the Director of Healthcare and Family Services | 3 |
| or any agent authorized by the Director of Healthcare and | 4 |
| Family Services to reimburse or procure prescription drugs at a | 5 |
| negotiated rate pursuant to a program of which the Department | 6 |
| of Healthcare and Family Services is the third party. | 7 |
| "Pharmacy" has the meaning given to the term in the | 8 |
| Pharmacy Practice Act. | 9 |
| "Pharmacy network provider" means a pharmacist or pharmacy | 10 |
| that has a contractual relationship with a health benefit plan | 11 |
| or pharmacy benefit manager to provide pharmacist services. | 12 |
| "Pharmacy reimbursement rate" means the amount a PBM pays | 13 |
| to a pharmacy or pharmacy network provider for prescription | 14 |
| drugs and services provided by the pharmacy or pharmacy network | 15 |
| provider to the PBM. | 16 |
| "Rebates" means any valuable consideration or inducement | 17 |
| to directly or indirectly affect or influence the dispensing of | 18 |
| pharmaceutical drugs, supplies, or services. | 19 |
| (a) "Third party prescription program" or "program" means | 20 |
| any system of
providing for the reimbursement of pharmaceutical | 21 |
| services and prescription
drug products offered or operated in | 22 |
| this State under a contractual arrangement
or agreement between | 23 |
| a provider of such services and another party who is
not the | 24 |
| consumer of those services and products. Such programs may | 25 |
| include, but need not be limited to, employee benefit
plans | 26 |
| whereby a consumer receives prescription drugs or other |
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| pharmaceutical
services and those services are paid for by
an | 2 |
| agent of the employer or others.
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| (b) "Third party program administrator" or "administrator" | 4 |
| means any person,
partnership or corporation who issues or | 5 |
| causes to be issued any payment
or reimbursement to a provider | 6 |
| for services rendered pursuant to a third
party prescription | 7 |
| program, but does not include the Director of Healthcare and | 8 |
| Family Services or any agent authorized by
the Director to | 9 |
| reimburse a provider of services rendered pursuant to a
program | 10 |
| of which the Department of Healthcare and Family Services is | 11 |
| the third party.
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| (Source: P.A. 95-331, eff. 8-21-07.)
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| (215 ILCS 5/512-4) (from Ch. 73, par. 1065.59-4)
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| Sec. 512-4. Licensure; application and fees Registration . | 15 |
| (a) No person, partnership, corporation, or other entity | 16 |
| may act as a PBM in this State without being licensed by the | 17 |
| Division. | 18 |
| (b) Each applicant for licensure must file with the | 19 |
| Director the following information and documents: | 20 |
| (1) the name of the company and the state or country | 21 |
| under the laws of which the company is organized or | 22 |
| authorized; | 23 |
| (2) the title of the Act under or by which the company | 24 |
| was incorporated or organized, the date of its | 25 |
| incorporation or organization, and, if a corporation, the |
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| period of its duration; | 2 |
| (3) an organizational chart describing the | 3 |
| relationship between the PBM, its parent organization and | 4 |
| any affiliates, including the state or country of domicile | 5 |
| and the primary business of each entity; | 6 |
| (4) a list of the names, addresses, official positions, | 7 |
| and biographical affidavits of the persons responsible for | 8 |
| the conduct of the affairs of the PBM; | 9 |
| (5) sample copies of contracts utilized by the PBM | 10 |
| between the PBM and covered entities; if the terms and | 11 |
| conditions in such agreements include significant, | 12 |
| substantial, or material variations, the filing of one | 13 |
| complete sample agreement together with a description of | 14 |
| all variable terms and conditions may satisfy this | 15 |
| requirement; and | 16 |
| (6) such other information as the Director may | 17 |
| reasonably require. | 18 |
| (c) A licensee shall keep current the information required | 19 |
| to be disclosed in its application for licensure by reporting | 20 |
| all material changes or additions to the Director within 30 | 21 |
| days after the end of the month of each change or addition. A | 22 |
| material change or addition includes any modification of the | 23 |
| information that has a significant effect on the operation of | 24 |
| the PBM. | 25 |
| (d) Beginning on January 1, 2009, each PBM doing business | 26 |
| in this State must pay to the Director an initial licensure fee |
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| of $1,000.00. Thereafter, annually on or before January 1 of | 2 |
| each year, a PBM doing business in this State that seeks to | 3 |
| renew a PBM license must pay to the Director a renewal fee of | 4 |
| $250. All fees collected under this Section shall be deposited | 5 |
| into the Insurance Producer Administration Fund. All
third | 6 |
| party prescription programs and
administrators doing business | 7 |
| in the State shall register with the Director
of Insurance. The | 8 |
| Director
shall promulgate regulations establishing criteria
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| for registration in accordance with the terms of this Article. | 10 |
| The Director
may by rule establish an annual registration fee | 11 |
| for each
third party administrator.
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| (Source: P.A. 82-1005.)
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| (215 ILCS 5/512-5) (from Ch. 73, par. 1065.59-5)
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| Sec. 512-5. Disciplinary grounds; multiple accounts | 15 |
| Fiduciary and Bonding Requirements . | 16 |
| (a) The Director may place on probation, suspend, revoke, | 17 |
| or refuse
to issue or renew a pharmaceutical benefits | 18 |
| management program or PBM license or may levy a civil penalty | 19 |
| in accordance with this Section or take any combination of | 20 |
| actions for any one or more of the following causes: | 21 |
| (1) Providing incorrect, misleading, incomplete, or | 22 |
| materially untrue information in the license application. | 23 |
| (2) Violating any provision of this Law or the | 24 |
| insurance laws of this or another state or violating any | 25 |
| rule, subpoena, or order of the Director of this or another |
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| state's insurance commissioner. | 2 |
| (3) Obtaining or attempting to obtain a license through | 3 |
| misrepresentation or fraud. | 4 |
| (4) Improperly withholding, misappropriating, or | 5 |
| converting any moneys or properties received in the course | 6 |
| of doing business. | 7 |
| (5) Intentionally misrepresenting the terms of any | 8 |
| contract or agreement
between a PBM and a covered entity. | 9 |
| (6 )Having admitted to or been found to have committed | 10 |
| any unfair trade practice or fraud. | 11 |
| (7) Using fraudulent, coercive, or dishonest practices | 12 |
| or demonstrating incompetence, untrustworthiness, or | 13 |
| financial irresponsibility in the conduct of business in | 14 |
| this State or elsewhere. | 15 |
| (8) Having a professional license or registration or | 16 |
| its equivalent denied, suspended, or revoked in any other | 17 |
| state, province, district,
or territory. | 18 |
| (9) Forging a name to an application. | 19 |
| (10) Failing to pay any tax or fee, as required by law. | 20 |
| (b) If the action by the Director is to deny renewal, | 21 |
| suspend, or revoke a license or to deny an application for a | 22 |
| licensure, the Director shall notify the applicant and advise, | 23 |
| in writing, the applicant of the reason for the suspension, | 24 |
| revocation, or denial. The applicant or licensee may make | 25 |
| written demand upon the Director within 30 days after the date | 26 |
| of mailing of notice for a hearing before the Director to |
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| determine the reasonableness of the Director's action. The | 2 |
| hearing must be held within not fewer than 20 days nor more | 3 |
| than 30 days after the mailing of the notice of hearing and | 4 |
| shall be held pursuant to the Illinois Administrative Code.
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| (c) In addition to or instead of any applicable denial, | 6 |
| suspension, or revocation of a license, an applicant or | 7 |
| licensee may, after hearing, be subject to a civil penalty. | 8 |
| (d) The Director has the authority to enforce the | 9 |
| provisions of and impose any penalty or remedy authorized by | 10 |
| this Article against any person or PBM who is under | 11 |
| investigation for or charged with a violation of this Law or | 12 |
| Code even if the license has been surrendered or has lapsed by | 13 |
| operation of law. | 14 |
| (e) Upon the suspension, denial, or revocation of a | 15 |
| license, the licensee having possession or custody of the | 16 |
| license shall promptly deliver it to the Director in person or | 17 |
| by mail. The Director shall publish all suspensions, denials, | 18 |
| or revocations after the suspension, denial, or revocation | 19 |
| becomes final. | 20 |
| (f) A licensee whose license is revoked or applicant whose | 21 |
| application is denied pursuant to this Section is ineligible to | 22 |
| apply for any pharmaceutical benefits management program or PBM | 23 |
| license under this Law for 3 years after the revocation or | 24 |
| denial. A pharmaceutical benefits management program or PBM | 25 |
| whose license as a pharmaceutical benefits management program | 26 |
| or PBM has been revoked, suspended, or denied may not be |
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| employed, contracted, or engaged in any related capacity during | 2 |
| the time the revocation, suspension, or denial is in effect. | 3 |
| (g) A PBM must inform the Director in a manner acceptable | 4 |
| to the Director of a change of address within 30 days after the | 5 |
| change. A
third party prescription program administrator
shall | 6 |
| (1) establish and
maintain a fiduciary account, separate and | 7 |
| apart from any and all other
accounts, for the receipt and | 8 |
| disbursement of funds for reimbursement of
providers of | 9 |
| services under the program, or (2) post,
or cause to be posted, | 10 |
| a bond of indemnity in an amount equal to not less
than 10% of | 11 |
| the total estimated annual reimbursements under the program.
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| The establishment of such fiduciary accounts and bonds | 13 |
| shall be consistent
with applicable State law.
If a bond of | 14 |
| indemnity is posted, it shall be held by the Director of | 15 |
| Insurance
for the benefit and indemnification of the providers | 16 |
| of services under the
third party prescription program.
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| (h) Any PBM
An administrator who operates more than one | 18 |
| pharmaceutical benefits management
third party prescription
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| program
may establish and maintain a separate fiduciary account | 20 |
| or bond of indemnity
for each such program, or may operate and | 21 |
| maintain a consolidated fiduciary
account or bond of indemnity | 22 |
| for all such programs.
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| The requirements of this subsection (h) Section do not | 24 |
| apply to any pharmaceutical benefits management
third party | 25 |
| prescription
program administered by or on behalf of any | 26 |
| insurance company, Health Maintenance Organization, Limited |
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| Health Service Organization, or Voluntary Health Services Plan
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| Care
Service Plan Corporation or Pharmaceutical Service Plan | 3 |
| Corporation
authorized
to do business in the State of Illinois.
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| (Source: P.A. 82-1005.)
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| (215 ILCS 5/512-6) (from Ch. 73, par. 1065.59-6)
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| Sec. 512-6. Notice. Notice of any change in the terms | 7 |
| of a pharmaceutical benefits management
third party | 8 |
| prescription
program,
including but not limited to drugs | 9 |
| covered, reimbursement rates, co-payments,
and dosage | 10 |
| quantity, shall be given to each enrolled pharmacy at least 30
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| days prior to the time it becomes effective.
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| (Source: P.A. 82-1005.)
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| (215 ILCS 5/512-7) (from Ch. 73, par. 1065.59-7)
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| Sec. 512-7. Required program and contractual Contractual | 15 |
| provisions.
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| (a) Any agreement or contract entered into in this State | 17 |
| between a PBM the
administrator of a program and a pharmacy | 18 |
| under a pharmaceutical benefits management program shall | 19 |
| include a statement of the
method and amount of reimbursement | 20 |
| to the pharmacy for services rendered to
covered persons | 21 |
| enrolled in the program, the frequency of payment by the PBM | 22 |
| program
administrator to the pharmacy for those services, and a | 23 |
| method for the
adjudication of complaints and the settlement of | 24 |
| disputes between the
contracting parties.
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| (b) Every prescription benefit management program shall | 2 |
| (1) A program shall provide an annual period of at least 30 | 3 |
| days
during which any pharmacy licensed under the Pharmacy | 4 |
| Practice Act
may elect to participate in the program under the | 5 |
| program terms for at
least one year. Beginning January 1, 2009, | 6 |
| all agreements between a pharmaceutical benefits management | 7 |
| program and any other person shall comply with the requirements | 8 |
| of this Law. To the extent that any such agreement renewed or | 9 |
| extended after December 31, 2008, fails to comply with the | 10 |
| requirements of this Law, such requirements shall be deemed to | 11 |
| be incorporated into those agreements by operation of law as of | 12 |
| the date of the renewal of execution.
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| (2) If compliance with the requirements of this | 14 |
| subsection (b) would
impair any provision of a contract | 15 |
| between a program and any other person,
and if the contract | 16 |
| provision was in existence before January 1, 1990,
then | 17 |
| immediately after the expiration of those contract | 18 |
| provisions the
program shall comply with the requirements | 19 |
| of this subsection (b).
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(3) This subsection (b) does not apply if:
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| (A) the program administrator is a licensed health | 22 |
| maintenance
organization that owns or controls a | 23 |
| pharmacy and that enters into an
agreement or contract | 24 |
| with that pharmacy in accordance with subsection (a); | 25 |
| or
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| (B) the program administrator is a licensed health |
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| maintenance
organization that is owned or controlled | 2 |
| by another entity that also owns
or controls a | 3 |
| pharmacy, and the administrator enters into an | 4 |
| agreement or
contract with that pharmacy in accordance | 5 |
| with subsection (a).
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| (4) This subsection (b) shall be inoperative after | 7 |
| October 31,
1992.
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| (c) (Blank). The program administrator shall cause to be | 9 |
| issued an identification
card to each person enrolled in the | 10 |
| program. The identification card
shall include:
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| (1) the name of the individual enrolled in the program; | 12 |
| and
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| (2) an expiration date if required under the | 14 |
| contractual arrangement or
agreement between a provider of | 15 |
| pharmaceutical services and prescription
drug products and | 16 |
| the third party prescription program administrator.
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| (Source: P.A. 95-689, eff. 10-29-07.)
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| (215 ILCS 5/512-7.5 new)
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| Sec. 512-7.5. Disclosures. | 20 |
| (a) A PBM or pharmaceutical manufacturer shall provide to a | 21 |
| covered entity all appropriate financial and utilization | 22 |
| information in aggregate relating to the cost of services to | 23 |
| that covered entity. A PBM or pharmaceutical manufacturer | 24 |
| providing information under this subsection (a) shall | 25 |
| designate that information as confidential. Information |
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| designated as confidential by a PBM and provided to a covered | 2 |
| entity under this subsection (a) shall not be disclosed by the | 3 |
| covered entity to any person without the consent of the PBM or | 4 |
| pharmaceutical manufacturer, except that disclosure may be | 5 |
| made in a court filing or when authorized by law or ordered by | 6 |
| a court of this State for good cause. Any unauthorized | 7 |
| disclosure by a PBM or covered entity of information that is | 8 |
| protected by the Illinois Trade Secrets Act shall result in a | 9 |
| civil penalty of $10,000 per incident and, where disclosure is | 10 |
| found to be willful, punitive damages may apply. | 11 |
| (b) A PBM shall disclose to the covered entity all | 12 |
| appropriate financial terms and arrangements for remuneration | 13 |
| of any kind resulting from arrangements between the PBM and any | 14 |
| labeler, including without limitation formulary management and | 15 |
| drug-switch programs and specifically excluding any financial | 16 |
| terms and arrangements with prescription drug manufacturers, | 17 |
| educational support, claims processing, and pharmacy network | 18 |
| fees that are charged from retail pharmacies and data sales | 19 |
| fees. Any and all information disclosed under this subsection | 20 |
| (b) may be designated as confidential. Information designated | 21 |
| as confidential by a PBM and provided to a covered entity under | 22 |
| this subsection (b) may not be disclosed by the covered entity | 23 |
| to any person without the consent of the PBM, except as may be | 24 |
| required in a court of law with proper jurisdiction or as | 25 |
| authorized by law. | 26 |
| (c) A PBM shall disclose to each covered entity and covered |
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| individual, either electronically or in writing and in a manner | 2 |
| calculated to be understood by layperson, all of the following | 3 |
| information: | 4 |
| (1) The amount of copayment, coinsurance, and | 5 |
| deductible associated with each and every tier of covered | 6 |
| prescription drugs. | 7 |
| (2) A notice to the covered individual advising the | 8 |
| covered individual to contact the PBM before filling or | 9 |
| obtaining a refill for a particular prescription drug the | 10 |
| covered individual is currently using to determine whether | 11 |
| there has been any change in (i) the requirements for | 12 |
| obtaining coverage for the drug or (ii) the amount that the | 13 |
| covered individual is required to pay out-of-pocket for the | 14 |
| drug. | 15 |
| (3) A notice to the covered individual advising the | 16 |
| covered individual to consider contacting his or her | 17 |
| prescribing provider to determine whether there is an | 18 |
| acceptable generic or other alternative prescription drug | 19 |
| that can be used to treat the covered individual's disease | 20 |
| or medical condition that is available at a lower | 21 |
| out-of-pocket level. | 22 |
| (d) Nothing in this Section shall prohibit a pharmacy | 23 |
| network provider from advising a covered individual of (i) | 24 |
| alternative generic prescription drugs that might be available | 25 |
| to the covered individual at a lower out-of-pocket level and | 26 |
| (ii) that the covered individual may contact his or her |
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| prescribing provider to determine whether there is an | 2 |
| acceptable alternative prescription drug that can be used to | 3 |
| treat the covered individual's disease or medical condition | 4 |
| that is available at a lower out-of-pocket level. | 5 |
| (215 ILCS 5/512-7.10 new)
| 6 |
| Sec. 512-7.10. Recoupment. A PBM shall provide the pharmacy | 7 |
| or pharmacy network provider a remittance advice which must | 8 |
| include an explanation of a recoupment or offset taken by a | 9 |
| PBM, if any. The recoupment explanation shall, at a minimum, | 10 |
| include the name of the patient, the date of dispensing, the | 11 |
| prescription drug or drugs dispensed, the recoupment amount, | 12 |
| and the reason for the recoupment or offset. In addition, a PBM | 13 |
| shall provide with the remittance advice a telephone number or | 14 |
| mailing address to initiate an appeal of the recoupment or | 15 |
| offset.
| 16 |
| (215 ILCS 5/512-8) (from Ch. 73, par. 1065.59-8)
| 17 |
| Sec. 512-8. Cancellation procedures. | 18 |
| (a) The pharmacy benefits manager
administrator of a | 19 |
| program
shall notify all pharmacies enrolled in the program of | 20 |
| any cancellation
of the coverage of benefits of any group | 21 |
| enrolled in the program at least
30 days prior to the effective | 22 |
| date of such cancellation.
However, if the PBM
administrator of | 23 |
| a program is not notified at least 45
days prior to the | 24 |
| effective date of such cancellation, the PBM
administrator
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| shall notify all pharmacies enrolled in the program of the | 2 |
| cancellation
as soon as practicable after having received | 3 |
| notice.
| 4 |
| (b) When a program is terminated, all persons enrolled | 5 |
| therein shall be
so notified by the PBM , and the employer shall | 6 |
| make every reasonable effort to gain
possession of any plan | 7 |
| identification cards in such persons' possession .
| 8 |
| (c) Any person who intentionally uses a program | 9 |
| identification card to
obtain services from a pharmacy after | 10 |
| having received notice of the cancellation
of his benefits | 11 |
| shall be guilty of a Class C misdemeanor. Persons shall
be | 12 |
| liable to the PBM
program administrator for all monies paid by | 13 |
| the PBM
program
administrator for any services received | 14 |
| pursuant to
any improper use of
the identification card.
| 15 |
| (Source: P.A. 82-1005.)
| 16 |
| (215 ILCS 5/512-9) (from Ch. 73, par. 1065.59-9)
| 17 |
| Sec. 512-9. Denial of Payment. | 18 |
| (a) No PBM
administrator shall deny payment
to any pharmacy | 19 |
| for covered pharmaceutical services or prescription drug
| 20 |
| products rendered as a result of the misuse, fraudulent or | 21 |
| illegal use of
an identification card unless such | 22 |
| identification card had expired, been
noticeably altered, or | 23 |
| the pharmacy was notified of the cancellation of
such card. In | 24 |
| lieu of notifying pharmacies which have a common ownership,
the | 25 |
| PBM
administrator may notify a party designated by the pharmacy |
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LRB095 18675 RAS 48829 a |
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| to receive
such notice, in which case, notification shall not | 2 |
| become effective until
5 calendar days after the designee | 3 |
| receives notification.
| 4 |
| (b) No PBM
program administrator may withhold any payment | 5 |
| to any pharmacy
for covered pharmaceutical services or | 6 |
| prescription drug products beyond
the time period specified in | 7 |
| the payment schedule provisions of the agreement,
except for | 8 |
| individual claims for payment which have been returned to the | 9 |
| pharmacy
as incomplete or illegible. Such returned claims shall | 10 |
| be paid if resubmitted
by the pharmacy to the PBM
program | 11 |
| administrator with the appropriate corrections made. | 12 |
| (c) No PBM may deny a claim for payment for filling a | 13 |
| prescription from a network pharmacy provider that exceeds the | 14 |
| MAC, unless the PBM advises the network pharmacy provider how | 15 |
| to obtain the particular drug at the MAC rate.
| 16 |
| (Source: P.A. 82-1005.)
| 17 |
| (215 ILCS 5/512-10) (from Ch. 73, par. 1065.59-10)
| 18 |
| Sec. 512-10. Failure to obtain licensure Register . Any | 19 |
| pharmaceutical benefits management
third party prescription | 20 |
| program
or PBM that
administrator which operates without a | 21 |
| license certificate of registration or
fails to register with | 22 |
| the Director and pay the fee prescribed by this Article
shall | 23 |
| be construed to be an unauthorized insurer as defined in | 24 |
| Article VII
of this Code and shall be subject to all penalties | 25 |
| contained therein.
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LRB095 18675 RAS 48829 a |
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| 1 |
| The provisions of
the Article shall apply to all new | 2 |
| programs established
on or after January 1,
1983.
Existing | 3 |
| programs shall comply with the provisions
of this Article
on | 4 |
| the anniversary date of the programs that occurs on or
after | 5 |
| January 1,
1983.
| 6 |
| (Source: P.A. 82-1005.)
| 7 |
| (215 ILCS 5/512-11 new) | 8 |
| Sec. 512-11. Examination of business and affairs. | 9 |
| (a) The Director may, when and as often as the Director | 10 |
| deems it reasonably necessary to protect the interests of the | 11 |
| public, examine the business and affairs of any licensed PBM. | 12 |
| (b) Licensees shall maintain for a period of 5 years copies | 13 |
| of all documents, books, records, accounts, papers, and any or | 14 |
| all computer or other recordings relating to the licensee's | 15 |
| business and affairs of operating a pharmaceutical benefit | 16 |
| management program. | 17 |
| (c) Every licensee or person from whom information is | 18 |
| sought, including all officers, directors, employees and | 19 |
| agents of any licensee or person from whom information is | 20 |
| sought, shall provide to the examiners timely, convenient, and | 21 |
| free access at all reasonable hours at the licensee's or | 22 |
| person's offices to all books, records, accounts, papers, | 23 |
| documents, assets, and computer or other recordings relating to | 24 |
| the property, assets, business, and affairs of the licensee | 25 |
| being examined. The officers, directors, employees, and agents |
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LRB095 18675 RAS 48829 a |
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| of the licensee or person shall facilitate the examination and | 2 |
| aid in the examination so far as it is in their power to do so. | 3 |
| The refusal of a licensee, through its officers, directors, | 4 |
| employees, or agents, to submit to examination or to comply | 5 |
| with any reasonable written request of the Director shall be | 6 |
| grounds for suspension, revocation, or denial of issuance or | 7 |
| renewal of any license or authority held by the licensee | 8 |
| pursuant to this Law. | 9 |
| (d) The Director or his or her designee shall have the | 10 |
| power to issue subpoenas, administer oaths, and examine under | 11 |
| oath any person as to any matter pertinent to the examination. | 12 |
| Upon the failure or refusal of a person to obey a subpoena, the | 13 |
| Director may petition a court of competent jurisdiction, and | 14 |
| upon proper showing, the court may enter an order compelling | 15 |
| the witness to appear and testify or produce documentary | 16 |
| evidence. | 17 |
| (e) When making an examination under this Law, the Director | 18 |
| may retain attorneys, appraisers, independent actuaries, | 19 |
| independent certified public accountants, or other | 20 |
| professionals and specialists as examiners. The costs of | 21 |
| retaining the examiners, including their work, travel, and | 22 |
| living expenses shall be borne by the licensee that is the | 23 |
| subject of the examination. | 24 |
| (215 ILCS 5/512-12 new) | 25 |
| Sec. 512-12. Fines and penalties. In addition to or instead |
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LRB095 18675 RAS 48829 a |
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| of any applicable denial, suspension, or revocation of a | 2 |
| license issued under this Law, a licensee may, after a hearing, | 3 |
| be subject to a civil penalty of up to $500,000 for each cause | 4 |
| of denial, suspension, or revocation. | 5 |
| Any licensee or other person who willfully or repeatedly | 6 |
| fails to observe or who otherwise violates any of the | 7 |
| provisions of this Law or this Code or any rule adopted or | 8 |
| final order entered thereunder shall, by civil penalty, forfeit | 9 |
| to the Division a sum not to exceed $5,000. Each day during | 10 |
| which a violation occurs constitutes a separate offense. | 11 |
| (215 ILCS 5/512-13 new)
| 12 |
| Sec. 512-13. Rulemaking. The Director shall have the | 13 |
| authority to adopt any rules necessary for the implementation | 14 |
| and administration of this Article. ".
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