Full Text of SB2827 100th General Assembly
SB2827 100TH GENERAL ASSEMBLY |
| | 100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018 SB2827 Introduced 2/13/2018, by Sen. Laura M. Murphy SYNOPSIS AS INTRODUCED: |
| 305 ILCS 5/5-5.12 | from Ch. 23, par. 5-5.12 |
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Amends the Medical Assistance Article of the Illinois Public Aid Code. Provides that drugs prescribed to residents of the following facilities are not subject to prior approval as a result of the 4-prescription limit: long-term care facilities as defined in the Nursing Home Care Act; community-integrated living arrangements as defined in the Community-Integrated Living Arrangements Licensure and Certification Act; and supportive living facilities as defined in the Code.
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| | | FISCAL NOTE ACT MAY APPLY | |
| | 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 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 | 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 frequency | 13 | | (including "as needed") in a dosage, or in conjunction with | 14 | | other psychotropic medications to a nursing home resident or to | 15 | | a resident of a facility licensed under the ID/DD Community | 16 | | Care Act or the MC/DD Act, may constitute a chemical restraint | 17 | | or an "unnecessary drug" as defined by the Nursing Home Care | 18 | | Act or Titles XVIII and XIX of the Social Security Act and the | 19 | | implementing rules and regulations. The Department shall | 20 | | require prior approval for any such medication prescribed for a | 21 | | nursing home resident or to a resident of a facility licensed | 22 | | under the ID/DD Community Care Act or the MC/DD Act, that | 23 | | appears to be a chemical restraint or an unnecessary drug. The | 24 | | Department shall consult with the Department of Human Services | 25 | | Division of Mental Health in developing a protocol and criteria | 26 | | for deciding whether to grant such prior approval. |
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| 1 | | (g) The Department may by rule provide for reimbursement of | 2 | | the dispensing of a 90-day supply of a generic or brand name, | 3 | | non-narcotic maintenance medication in circumstances where it | 4 | | is cost effective. | 5 | | (g-5) On and after July 1, 2012, the Department may require | 6 | | the dispensing of drugs to nursing home residents be in a 7-day | 7 | | supply or other amount less than a 31-day supply. The | 8 | | Department shall pay only one dispensing fee per 31-day supply. | 9 | | (h) Effective July 1, 2011, the Department shall | 10 | | discontinue coverage of select over-the-counter drugs, | 11 | | including analgesics and cough and cold and allergy | 12 | | medications. | 13 | | (h-5) On and after July 1, 2012, the Department shall | 14 | | impose utilization controls, including, but not limited to, | 15 | | prior approval on specialty drugs, oncolytic drugs, drugs for | 16 | | the treatment of HIV or AIDS, immunosuppressant drugs, and | 17 | | biological products in order to maximize savings on these | 18 | | drugs. The Department may adjust payment methodologies for | 19 | | non-pharmacy billed drugs in order to incentivize the selection | 20 | | of lower-cost drugs. For drugs for the treatment of AIDS, the | 21 | | Department shall take into consideration the potential for | 22 | | non-adherence by certain populations, and shall develop | 23 | | protocols with organizations or providers primarily serving | 24 | | those with HIV/AIDS, as long as such measures intend to | 25 | | maintain cost neutrality with other utilization management | 26 | | controls such as prior approval.
For hemophilia, the Department |
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| 1 | | shall develop a program of utilization review and control which | 2 | | may include, in the discretion of the Department, prior | 3 | | approvals. The Department may impose special standards on | 4 | | providers that dispense blood factors which shall include, in | 5 | | the discretion of the Department, staff training and education; | 6 | | patient outreach and education; case management; in-home | 7 | | patient assessments; assay management; maintenance of stock; | 8 | | emergency dispensing timeframes; data collection and | 9 | | reporting; dispensing of supplies related to blood factor | 10 | | infusions; cold chain management and packaging practices; care | 11 | | coordination; product recalls; and emergency clinical | 12 | | consultation. The Department may require patients to receive a | 13 | | comprehensive examination annually at an appropriate provider | 14 | | in order to be eligible to continue to receive blood factor. | 15 | | (i) On and after July 1, 2012, the Department shall reduce | 16 | | any rate of reimbursement for services or other payments or | 17 | | alter any methodologies authorized by this Code to reduce any | 18 | | rate of reimbursement for services or other payments in | 19 | | accordance with Section 5-5e. | 20 | | (j) On and after July 1, 2012, the Department shall impose | 21 | | limitations on prescription drugs such that the Department | 22 | | shall not provide reimbursement for more than 4 prescriptions, | 23 | | including 3 brand name prescriptions, for distinct drugs in a | 24 | | 30-day period, unless prior approval is received for all | 25 | | prescriptions in excess of the 4-prescription limit. Drugs in | 26 | | the following therapeutic classes shall not be subject to prior |
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| 1 | | approval as a result of the 4-prescription limit: | 2 | | immunosuppressant drugs, oncolytic drugs, anti-retroviral | 3 | | drugs, and, on or after July 1, 2014, antipsychotic drugs. On | 4 | | or after July 1, 2014, the Department may exempt children with | 5 | | complex medical needs enrolled in a care coordination entity | 6 | | contracted with the Department to solely coordinate care for | 7 | | such children, if the Department determines that the entity has | 8 | | a comprehensive drug reconciliation program. | 9 | | Drugs prescribed to residents of the following facilities | 10 | | are not subject to prior approval as a result of the | 11 | | 4-prescription limit: | 12 | | (1) Long-term care facilities as defined in Section | 13 | | 1-113 of the Nursing Home Care Act. | 14 | | (2) Community-integrated living arrangements as | 15 | | defined in the Community-Integrated Living Arrangements | 16 | | Licensure and Certification Act. | 17 | | (3) Supportive living facilities as defined in Section | 18 | | 5-5.01a of this Code. | 19 | | (k) No medication therapy management program implemented | 20 | | by the Department shall be contrary to the provisions of the | 21 | | Pharmacy Practice Act. | 22 | | (l) Any provider enrolled with the Department that bills | 23 | | the Department for outpatient drugs and is eligible to enroll | 24 | | in the federal Drug Pricing Program under Section 340B of the | 25 | | federal Public Health Services Act shall enroll in that | 26 | | program. No entity participating in the federal Drug Pricing |
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| 1 | | Program under Section 340B of the federal Public Health | 2 | | Services Act may exclude Medicaid from their participation in | 3 | | that program, although the Department may exclude entities | 4 | | defined in Section 1905(l)(2)(B) of the Social Security Act | 5 | | from this requirement. | 6 | | (Source: P.A. 98-463, eff. 8-16-13; 98-651, eff. 6-16-14; | 7 | | 99-180, eff. 7-29-15.)
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