Full Text of SB1807 98th General Assembly
SB1807sam003 98TH GENERAL ASSEMBLY | Sen. William Delgado Filed: 3/14/2013
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| 1 | | AMENDMENT TO SENATE BILL 1807
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1807 by replacing | 3 | | everything after the enacting clause with the following:
| 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 reimbursement | 9 | | under this
Article for prescription drugs provided to a | 10 | | recipient of aid under this
Article shall include the name of | 11 | | the prescriber or an acceptable
identification number as | 12 | | 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 |
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| 1 | | prescription
drug dispensed. The Illinois Department shall | 2 | | update its
information on the acquisition costs of all | 3 | | prescription drugs
no less frequently than every 30 days. | 4 | | However, the Illinois
Department may set the rate of | 5 | | reimbursement for the acquisition
cost, by rule, at a | 6 | | percentage of the current average wholesale
acquisition cost.
| 7 | | (c) (Blank).
| 8 | | (d) The Department shall review utilization of narcotic | 9 | | medications in the medical assistance program and impose | 10 | | utilization controls that protect against abuse.
| 11 | | (e) When making determinations as to which drugs shall be | 12 | | on a prior approval list, the Department shall include as part | 13 | | of the analysis for this determination, the degree to which a | 14 | | drug may affect individuals in different ways based on factors | 15 | | including the gender of the person taking the medication. | 16 | | (f) The Department shall cooperate with the Department of | 17 | | Public Health and the Department of Human Services Division of | 18 | | Mental Health in identifying psychotropic medications that, | 19 | | when given in a particular form, manner, duration, or frequency | 20 | | (including "as needed") in a dosage, or in conjunction with | 21 | | other psychotropic medications to a nursing home resident or to | 22 | | a resident of a facility licensed under the ID/DD Community | 23 | | Care Act, may constitute a chemical restraint or an | 24 | | "unnecessary drug" as defined by the Nursing Home Care Act or | 25 | | Titles XVIII and XIX of the Social Security Act and the | 26 | | implementing rules and regulations. The Department shall |
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| 1 | | require prior approval for any such medication prescribed for a | 2 | | nursing home resident or to a resident of a facility licensed | 3 | | under the ID/DD Community Care Act, that appears to be a | 4 | | chemical restraint or an unnecessary drug. The Department shall | 5 | | consult with the Department of Human Services Division of | 6 | | Mental Health in developing a protocol and criteria for | 7 | | deciding whether to grant such prior approval. | 8 | | (g) The Department may by rule provide for reimbursement of | 9 | | the dispensing of a 90-day supply of a generic or brand name, | 10 | | non-narcotic maintenance medication in circumstances where it | 11 | | is cost effective. | 12 | | (g-5) On and after July 1, 2012, the Department may require | 13 | | the dispensing of drugs to nursing home residents be in a 7-day | 14 | | supply or other amount less than a 31-day supply. The | 15 | | Department shall pay only one dispensing fee per 31-day supply. | 16 | | (h) Effective July 1, 2011, the Department shall | 17 | | discontinue coverage of select over-the-counter drugs, | 18 | | including analgesics and cough and cold and allergy | 19 | | medications. | 20 | | (h-5) On and after July 1, 2012, the Department shall | 21 | | impose utilization controls, including, but not limited to, | 22 | | prior approval on specialty drugs, oncolytic drugs, drugs for | 23 | | the treatment of HIV or AIDS, immunosuppressant drugs, and | 24 | | biological products in order to maximize savings on these | 25 | | drugs. The Department may adjust payment methodologies for | 26 | | non-pharmacy billed drugs in order to incentivize the selection |
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| 1 | | of lower-cost drugs. For drugs for the treatment of AIDS, the | 2 | | Department shall take into consideration the potential for | 3 | | non-adherence by certain populations, and shall develop | 4 | | protocols with organizations or providers primarily serving | 5 | | those with HIV/AIDS, as long as such measures intend to | 6 | | maintain cost neutrality with other utilization management | 7 | | controls such as prior approval.
For hemophilia, the Department | 8 | | shall develop a program of utilization review and control which | 9 | | may include, in the discretion of the Department, prior | 10 | | approvals. The Department may impose special standards on | 11 | | providers that dispense blood factors which shall include, in | 12 | | the discretion of the Department, staff training and education; | 13 | | patient outreach and education; case management; in-home | 14 | | patient assessments; assay management; maintenance of stock; | 15 | | emergency dispensing timeframes; data collection and | 16 | | reporting; dispensing of supplies related to blood factor | 17 | | infusions; cold chain management and packaging practices; care | 18 | | coordination; product recalls; and emergency clinical | 19 | | consultation. The Department may require patients to receive a | 20 | | comprehensive examination annually at an appropriate provider | 21 | | in order to be eligible to continue to receive blood factor. | 22 | | (i) On and after July 1, 2012, the Department shall reduce | 23 | | any rate of reimbursement for services or other payments or | 24 | | alter any methodologies authorized by this Code to reduce any | 25 | | rate of reimbursement for services or other payments in | 26 | | accordance with Section 5-5e. |
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| 1 | | (i) (Blank). | 2 | | (j) On and after July 1, 2012, the Department shall impose | 3 | | limitations on prescription drugs such that the Department | 4 | | shall not provide reimbursement for more than 4 prescriptions, | 5 | | including 3 brand name prescriptions, for distinct drugs in a | 6 | | 30-day period, unless prior approval is received for all | 7 | | prescriptions in excess of the 4-prescription limit. Drugs in | 8 | | the following therapeutic classes shall not be subject to prior | 9 | | approval as a result of the 4-prescription limit: | 10 | | immunosuppressant drugs, oncolytic drugs, and anti-retroviral | 11 | | drugs. Antipsychotic and anticonvulsant drugs used to treat | 12 | | severe mental illness or epilepsy shall not be subject to prior | 13 | | approval as a result of the 4-prescription limit and shall not | 14 | | count toward the monthly prescription limit when used for the | 15 | | following disorders: post-traumatic stress disorder, | 16 | | schizophrenia, schizoaffective disorder, bipolar disorder, | 17 | | panic disorder, or epilepsy. | 18 | | (k) No medication therapy management program implemented | 19 | | by the Department shall be contrary to the provisions of the | 20 | | Pharmacy Practice Act. | 21 | | (l) Any provider enrolled with the Department that bills | 22 | | the Department for outpatient drugs and is eligible to enroll | 23 | | in the federal Drug Pricing Program under Section 340B of the | 24 | | federal Public Health Services Act shall enroll in that | 25 | | program. No entity participating in the federal Drug Pricing | 26 | | Program under Section 340B of the federal Public Health |
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| 1 | | Services Act may exclude Medicaid from their participation in | 2 | | that program, although the Department may exclude entities | 3 | | defined in Section 1905(l)(2)(B) of the Social Security Act | 4 | | from this requirement. | 5 | | (Source: P.A. 96-1269, eff. 7-26-10; 96-1372, eff. 7-29-10; | 6 | | 96-1501, eff. 1-25-11; 97-38, eff. 6-28-11; 97-74, eff. | 7 | | 6-30-11; 97-333, eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, | 8 | | eff. 6-14-12; 97-813, eff. 7-13-12; revised 8-3-12.)".
| 9 | | Section 99. Effective date. This Act takes effect upon | 10 | | becoming law.".
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