Public Act 096-0766
 
HB0152 Enrolled LRB096 02980 RPM 12994 b

    AN ACT concerning insurance.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 1. Short title. This Act may be cited as the Organ
Transplant Medication Notification Act.
 
    Section 5. Applicability. This Act shall apply solely to
cases of immunosuppressive therapy when (i) an
immunosuppressant drug has been prescribed to a patient to
prevent the rejection of transplanted organs and tissues and
(ii) as set forth in Section 15 of this Act, a prescribing
physician has indicated on a prescription "may not substitute".
This Act does not apply to medication orders issued for
immunosuppressant drugs for any in-patient care in a licensed
hospital.
 
    Section 10. Definitions. For the purpose of this Act:
    "Health insurance policy or health care service plan" means
any policy of health or accident insurance subject to the
provisions of the Illinois Insurance Code, Health Maintenance
Organization Act, Voluntary Health Services Plan Act, Counties
Code, Municipal Code, School Code, and State Employees Group
Insurance Act.
    "Immunosuppressant drugs" mean drugs that are used in
immunosuppressive therapy to inhibit or prevent the activity of
the immune system. "Immunosuppressant drugs" are used
clinically to prevent the rejection of transplanted organs and
tissues. "Immunosuppressant drugs" do not include drugs for the
treatment of autoimmune diseases or diseases that are most
likely of autoimmune origin.
 
    Section 15. Quality assurance in patient care. In
accordance with the Pharmacy Practice Act, when a prescribing
physician has indicated on a prescription "may not substitute",
a health insurance policy or health care service plan that
covers immunosuppressant drugs may not require or cause a
pharmacist to interchange another immunosuppressant drug or
formulation issued on behalf of a person to inhibit or prevent
the activity of the immune system of a patient to prevent the
rejection of transplanted organs and tissues without
notification and the documented consent of the prescribing
physician and the patient, or the parent or guardian if the
patient is a child, or the spouse of a patient who is
authorized to consent to the treatment of the person.
    Except as provided by subsections (a), (b), and (c) of
Section 20 of this Act, patient co-payments, deductibles, or
other charges for the prescribed drug for which another
immunosuppressant drug or formulation is not interchanged
shall remain the same for the enrollment period established by
the health insurance policy or plan.
 
    Section 20. Provision of notice; formulary changes.
    (a) At least 60 days prior to making any formulary change
that alters the terms of coverage for a patient receiving
immunosuppressant drugs or discontinues coverage for a
prescribed immunosuppressant drug that a patient is receiving,
a policy or plan sponsor must, to the extent possible, notify
the prescribing physician and the patient, or the parent or
guardian if the patient is a child, or the spouse of a patient
who is authorized to consent to the treatment of the patient.
The notification shall be in writing and shall disclose the
formulary change, indicate that the prescribing physician may
initiate an appeal, and include information regarding the
procedure for the prescribing physician to initiate the policy
or plan sponsor's appeal process.
    (b) As an alternative to providing written notice, a policy
or plan sponsor may provide the notice electronically if, and
only if, the patient affirmatively elects to receive such
notice electronically. The notification shall disclose the
formulary change, indicate that the prescribing physician may
initiate an appeal, and include information regarding the
procedure for the prescribing physician to initiate the policy
or plan sponsor's appeal process.
    (c) At the time a patient requests a refill of the
immunosuppressant drug, a policy or plan sponsor may provide
the patient with the written notification required under
subsection (a) of this Section along with a 60-day supply of
the immunosuppressant drug under the same terms as previously
allowed.
    (d) Nothing in this Section shall prohibit insurers or
pharmacy benefit managers from using managed pharmacy care
tools, including, but not limited to, formulary tiers, generic
substitution, therapeutic interchange, prior authorization, or
step therapy, so long as an exception process is in place
allowing the prescriber to petition for coverage of a
non-preferred drug if sufficient clinical reasons justify an
exception to the normal protocol.