Full Text of SB1359 99th General Assembly
SB1359sam001 99TH GENERAL ASSEMBLY | Sen. Linda Holmes Filed: 3/9/2015
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| 1 | | AMENDMENT TO SENATE BILL 1359
| 2 | | AMENDMENT NO. ______. Amend Senate Bill 1359 by replacing | 3 | | everything after the enacting clause with the following:
| 4 | | "Section 5. The Illinois Insurance Code is amended by | 5 | | adding Section 356z.23 as follows: | 6 | | (215 ILCS 5/356z.23 new) | 7 | | Sec. 356z.23. Specialty tier prescription coverage. | 8 | | (a) As used in this Section: | 9 | | "Coinsurance" means a cost-sharing amount set as a | 10 | | percentage of the total cost of a drug. | 11 | | "Copayment" means a cost-sharing amount set as a dollar | 12 | | value. | 13 | | "Non-preferred drug" means a drug in a tier designed for | 14 | | certain drugs deemed non-preferred and therefore subject to | 15 | | higher cost-sharing amounts than preferred drugs. | 16 | | "Preferred drug" means a drug in a tier designed for |
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| 1 | | certain drugs deemed preferred and therefore subject to lower | 2 | | cost-sharing amounts than non-preferred drugs. | 3 | | "Tiered formulary" means a formulary that provides | 4 | | coverage for prescription drugs as part of a policy of health | 5 | | and accident insurance for which cost sharing, deductibles, or | 6 | | coinsurance obligations are determined by category or tier of | 7 | | prescription drugs and includes at least 2 different tiers. | 8 | | (b) On or after the effective date of this amendatory Act | 9 | | of the 99th General Assembly, every insurer that amends, | 10 | | delivers, issues, or renews individual and group accident and | 11 | | health policies providing coverage for prescription drugs | 12 | | shall ensure that: | 13 | | (1) for insurance plans rated platinum, gold, and | 14 | | silver level, as defined in 45 CFR 156.140, and regardless | 15 | | of whether or not the plan was acquired through an exchange | 16 | | authorized under the federal Patient Protection and | 17 | | Affordable Care Act, any required copayment or coinsurance | 18 | | applicable to drugs does not exceed $100 per month for up | 19 | | to a 30-day supply of any single drug; and | 20 | | (2) for bronze plans, as defined in 45 CFR 156.140, and | 21 | | regardless of whether or not the plan was acquired through | 22 | | an exchange authorized under the federal Patient | 23 | | Protection and Affordable Care Act, any required copayment | 24 | | or coinsurance applicable to drugs does not exceed $200 per | 25 | | month for up to a 30-day supply of any single drug. | 26 | | (c) The limits described in subsection (b) of this Section |
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| 1 | | shall be inclusive of any patient out-of-pocket spending, | 2 | | including payments towards any deductibles, copayments, or | 3 | | coinsurance and shall be applicable before any applicable | 4 | | deductible is reached. | 5 | | (d) An insurance plan that meets the requirements for a | 6 | | catastrophic plan, as defined in 45 CFR 156.155(a), shall be | 7 | | exempt from the requirements of subsection (b) of this Section. | 8 | | (e) Subject to subsection (f) of this Section, the limits | 9 | | in subsection (b) of this Section shall apply at any point in | 10 | | the benefit design, including before any after any applicable | 11 | | deductible is reached. | 12 | | (f) For any enrollee that is enrolled in a policy that, but | 13 | | for the requirements of subsection (b) of this Section, would | 14 | | be a high deductible health plan as defined in Section | 15 | | 223(c)(2)(A) of the Internal Revenue Code of 1986, the limits | 16 | | described in subsection (b) of this Section shall be applicable | 17 | | only after the minimum annual deductible specified in Section | 18 | | 223(c)(2)(A) of the Internal Revenue Code of 1986 is reached. | 19 | | (g) An insurer that issues policies of accident and health | 20 | | insurance that provides coverage for prescription drugs shall | 21 | | implement an exceptions process that allows enrollees to | 22 | | request an exception to the formulary. An insurer may use its | 23 | | existing medical exceptions process to satisfy this | 24 | | requirement. Under such an exception, a non-formulary drug | 25 | | shall be deemed covered under the formulary if the prescribing | 26 | | physician determines that the formulary drug for treatment of |
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| 1 | | the same condition either would not be as effective for the | 2 | | individual, or would have adverse effects for the individual, | 3 | | or both. If an enrollee is denied an exception, the denial | 4 | | shall be considered an adverse coverage determination and will | 5 | | be subject to the health plan internal and external review | 6 | | processes. | 7 | | (h) On or after the effective date of this amendatory Act | 8 | | of the 99th General Assembly, every insurer that amends, | 9 | | delivers, issues, or renews individual and group accident and | 10 | | health policies providing coverage for prescription drugs | 11 | | shall ensure that beneficiary's annual out-of-pocket | 12 | | expenditures for prescription drugs are limited to no more than | 13 | | 50% of the dollar amounts in effect under Section 1302(c)(1) of | 14 | | the federal Patient Protection and Affordable Care Act for | 15 | | self-only and family coverage, respectively. | 16 | | (i) An insurer that issues policies of accident and health | 17 | | policies that provides coverage for prescription drugs and uses | 18 | | a tiered formulary shall implement an exceptions process that | 19 | | allows enrollees to request an exception to the tiered | 20 | | cost-sharing structure. Under an exception, a non-preferred | 21 | | drug may be covered under the cost sharing applicable for | 22 | | preferred drugs if the prescribing health care provider | 23 | | determines that the preferred drug for treatment of the same | 24 | | condition either would not be as effective for the individual, | 25 | | would have adverse effects for the individual, or both. If an | 26 | | enrollee is denied a cost-sharing exception, the denial shall |
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| 1 | | be considered an adverse event and shall be subject to the | 2 | | health plan's internal review process. | 3 | | (j) Nothing in this Section shall be construed to require | 4 | | an insurer that issues accident and health policies: | 5 | | (1) provide coverage for any additional drugs not | 6 | | otherwise required by law; | 7 | | (2) implement specific utilization management | 8 | | techniques, such as prior authorization or step therapy; or | 9 | | (3) cease utilization of tiered cost-sharing | 10 | | structures, including those strategies used to incentivize | 11 | | use of preventive services, disease management, and | 12 | | low-cost treatment options. | 13 | | (k) Nothing in this Section shall be construed to require a | 14 | | pharmacist to substitute a drug without the consent of the | 15 | | prescribing physician. | 16 | | (l) The Director shall adopt rules outlining the | 17 | | enforcement processes for this Section.
| 18 | | Section 99. Effective date. This Act takes effect January | 19 | | 1, 2016.".
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