Illinois General Assembly - Full Text of HB4943
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Full Text of HB4943  102nd General Assembly




State of Illinois
2021 and 2022


Introduced 1/27/2022, by Rep. Deanne M. Mazzochi


215 ILCS 5/513b1

    Amends the Illinois Insurance Code. In provisions concerning pharmacy benefit manager contracts, provides that if a retail price is to be used by a pharmacy benefit manager to calculate or estimate a copayment for a drug, the pharmacy must either report the retail price for the drug and identify any programs available to retail customers of the pharmacy that an individual without prescription drug coverage would be eligible for at the retail pharmacy that could reduce the price of the drug, or reduce the retail price reported to account for the price reductions that would be generally or specifically available to the individual without prescription drug coverage. Changes the definition of "retail price".

LRB102 25487 BMS 34775 b





HB4943LRB102 25487 BMS 34775 b

1    AN ACT concerning regulation.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 513b1 as follows:
6    (215 ILCS 5/513b1)
7    Sec. 513b1. Pharmacy benefit manager contracts.
8    (a) As used in this Section:
9    "Biological product" has the meaning ascribed to that term
10in Section 19.5 of the Pharmacy Practice Act.
11    "Maximum allowable cost" means the maximum amount that a
12pharmacy benefit manager will reimburse a pharmacy for the
13cost of a drug.
14    "Maximum allowable cost list" means a list of drugs for
15which a maximum allowable cost has been established by a
16pharmacy benefit manager.
17    "Pharmacy benefit manager" means a person, business, or
18entity, including a wholly or partially owned or controlled
19subsidiary of a pharmacy benefit manager, that provides claims
20processing services or other prescription drug or device
21services, or both, for health benefit plans.
22    "Retail price" means the price that an individual without
23prescription drug coverage would pay at a retail pharmacy,



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1"Retail price" does not include a pharmacist dispensing fee,
2regardless of whether the drug is or is not subject to a
3copayment amount not including a pharmacist dispensing fee.
4    (b) A contract between a health insurer and a pharmacy
5benefit manager must require that the pharmacy benefit
7        (1) Update maximum allowable cost pricing information
8    at least every 7 calendar days.
9        (2) Maintain a process that will, in a timely manner,
10    eliminate drugs from maximum allowable cost lists or
11    modify drug prices to remain consistent with changes in
12    pricing data used in formulating maximum allowable cost
13    prices and product availability.
14        (3) Provide access to its maximum allowable cost list
15    to each pharmacy or pharmacy services administrative
16    organization subject to the maximum allowable cost list.
17    Access may include a real-time pharmacy website portal to
18    be able to view the maximum allowable cost list. As used in
19    this Section, "pharmacy services administrative
20    organization" means an entity operating within the State
21    that contracts with independent pharmacies to conduct
22    business on their behalf with third-party payers. A
23    pharmacy services administrative organization may provide
24    administrative services to pharmacies and negotiate and
25    enter into contracts with third-party payers or pharmacy
26    benefit managers on behalf of pharmacies.



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1        (4) Provide a process by which a contracted pharmacy
2    can appeal the provider's reimbursement for a drug subject
3    to maximum allowable cost pricing. The appeals process
4    must, at a minimum, include the following:
5            (A) A requirement that a contracted pharmacy has
6        14 calendar days after the applicable fill date to
7        appeal a maximum allowable cost if the reimbursement
8        for the drug is less than the net amount that the
9        network provider paid to the supplier of the drug.
10            (B) A requirement that a pharmacy benefit manager
11        must respond to a challenge within 14 calendar days of
12        the contracted pharmacy making the claim for which the
13        appeal has been submitted.
14            (C) A telephone number and e-mail address or
15        website to network providers, at which the provider
16        can contact the pharmacy benefit manager to process
17        and submit an appeal.
18            (D) A requirement that, if an appeal is denied,
19        the pharmacy benefit manager must provide the reason
20        for the denial and the name and the national drug code
21        number from national or regional wholesalers.
22            (E) A requirement that, if an appeal is sustained,
23        the pharmacy benefit manager must make an adjustment
24        in the drug price effective the date the challenge is
25        resolved and make the adjustment applicable to all
26        similarly situated network pharmacy providers, as



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1        determined by the managed care organization or
2        pharmacy benefit manager.
3        (5) Allow a plan sponsor contracting with a pharmacy
4    benefit manager an annual right to audit compliance with
5    the terms of the contract by the pharmacy benefit manager,
6    including, but not limited to, full disclosure of any and
7    all rebate amounts secured, whether product specific or
8    generalized rebates, that were provided to the pharmacy
9    benefit manager by a pharmaceutical manufacturer.
10        (6) Allow a plan sponsor contracting with a pharmacy
11    benefit manager to request that the pharmacy benefit
12    manager disclose the actual amounts paid by the pharmacy
13    benefit manager to the pharmacy.
14        (7) Provide notice to the party contracting with the
15    pharmacy benefit manager of any consideration that the
16    pharmacy benefit manager receives from the manufacturer
17    for dispense as written prescriptions once a generic or
18    biologically similar product becomes available.
19    (c) In order to place a particular prescription drug on a
20maximum allowable cost list, the pharmacy benefit manager
21must, at a minimum, ensure that:
22        (1) if the drug is a generically equivalent drug, it
23    is listed as therapeutically equivalent and
24    pharmaceutically equivalent "A" or "B" rated in the United
25    States Food and Drug Administration's most recent version
26    of the "Orange Book" or have an NR or NA rating by



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1    Medi-Span, Gold Standard, or a similar rating by a
2    nationally recognized reference;
3        (2) the drug is available for purchase by each
4    pharmacy in the State from national or regional
5    wholesalers operating in Illinois; and
6        (3) the drug is not obsolete.
7    (d) A pharmacy benefit manager is prohibited from limiting
8a pharmacist's ability to disclose whether the cost-sharing
9obligation exceeds the retail price for a covered prescription
10drug, and the availability of a more affordable alternative
11drug, if one is available in accordance with Section 42 of the
12Pharmacy Practice Act.
13    (e) A health insurer or pharmacy benefit manager shall not
14require an insured to make a payment for a prescription drug at
15the point of sale in an amount that exceeds the lesser of:
16        (1) the applicable cost-sharing amount; or
17        (2) the retail price of the drug in the absence of
18    prescription drug coverage.
19    (f) This Section applies to contracts entered into or
20renewed on or after July 1, 2020.
21    (g) This Section applies to any group or individual policy
22of accident and health insurance or managed care plan that
23provides coverage for prescription drugs and that is amended,
24delivered, issued, or renewed on or after July 1, 2020.
25    (h) If a retail price is to be used by a pharmacy benefit
26manager to calculate or estimate a copayment for a drug, the



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1pharmacy must either:
2        (1) report the retail price for the drug and identify
3    any programs available to retail customers of the pharmacy
4    that an individual without prescription drug coverage
5    would be eligible for at the retail pharmacy that could
6    reduce the price of the drug, whether the programs are
7    specific to the drug or are generally available to
8    pharmacy customers; or
9        (2) reduce the retail price reported to account for
10    the price reductions that would be generally or
11    specifically available to the individual without
12    prescription drug coverage, including, but not limited to,
13    price reductions from senior discounts, volume discounts,
14    rebate coupons provided by the pharmacy, loyalty rewards,
15    or discounts earned through the payment of annual fees.
16(Source: P.A. 101-452, eff. 1-1-20.)