Bill Amendment: IL HB0465 | 2019-2020 | 101st General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: REGULATION-TECH
Status: 2019-08-23 - Public Act . . . . . . . . . 101-0452 [HB0465 Detail]
Download: Illinois-2019-HB0465-House_Amendment_001.html
Bill Title: REGULATION-TECH
Status: 2019-08-23 - Public Act . . . . . . . . . 101-0452 [HB0465 Detail]
Download: Illinois-2019-HB0465-House_Amendment_001.html
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1 | AMENDMENT TO HOUSE BILL 465
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2 | AMENDMENT NO. ______. Amend House Bill 465 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 1. The Freedom of Information Act is amended by | ||||||
5 | changing Section 7.5 as follows:
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6 | (5 ILCS 140/7.5) | ||||||
7 | Sec. 7.5. Statutory exemptions. To the extent provided for | ||||||
8 | by the statutes referenced below, the following shall be exempt | ||||||
9 | from inspection and copying: | ||||||
10 | (a) All information determined to be confidential | ||||||
11 | under Section 4002 of the Technology Advancement and | ||||||
12 | Development Act. | ||||||
13 | (b) Library circulation and order records identifying | ||||||
14 | library users with specific materials under the Library | ||||||
15 | Records Confidentiality Act. | ||||||
16 | (c) Applications, related documents, and medical |
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1 | records received by the Experimental Organ Transplantation | ||||||
2 | Procedures Board and any and all documents or other records | ||||||
3 | prepared by the Experimental Organ Transplantation | ||||||
4 | Procedures Board or its staff relating to applications it | ||||||
5 | has received. | ||||||
6 | (d) Information and records held by the Department of | ||||||
7 | Public Health and its authorized representatives relating | ||||||
8 | to known or suspected cases of sexually transmissible | ||||||
9 | disease or any information the disclosure of which is | ||||||
10 | restricted under the Illinois Sexually Transmissible | ||||||
11 | Disease Control Act. | ||||||
12 | (e) Information the disclosure of which is exempted | ||||||
13 | under Section 30 of the Radon Industry Licensing Act. | ||||||
14 | (f) Firm performance evaluations under Section 55 of | ||||||
15 | the Architectural, Engineering, and Land Surveying | ||||||
16 | Qualifications Based Selection Act. | ||||||
17 | (g) Information the disclosure of which is restricted | ||||||
18 | and exempted under Section 50 of the Illinois Prepaid | ||||||
19 | Tuition Act. | ||||||
20 | (h) Information the disclosure of which is exempted | ||||||
21 | under the State Officials and Employees Ethics Act, and | ||||||
22 | records of any lawfully created State or local inspector | ||||||
23 | general's office that would be exempt if created or | ||||||
24 | obtained by an Executive Inspector General's office under | ||||||
25 | that Act. | ||||||
26 | (i) Information contained in a local emergency energy |
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1 | plan submitted to a municipality in accordance with a local | ||||||
2 | emergency energy plan ordinance that is adopted under | ||||||
3 | Section 11-21.5-5 of the Illinois Municipal Code. | ||||||
4 | (j) Information and data concerning the distribution | ||||||
5 | of surcharge moneys collected and remitted by carriers | ||||||
6 | under the Emergency Telephone System Act. | ||||||
7 | (k) Law enforcement officer identification information | ||||||
8 | or driver identification information compiled by a law | ||||||
9 | enforcement agency or the Department of Transportation | ||||||
10 | under Section 11-212 of the Illinois Vehicle Code. | ||||||
11 | (l) Records and information provided to a residential | ||||||
12 | health care facility resident sexual assault and death | ||||||
13 | review team or the Executive Council under the Abuse | ||||||
14 | Prevention Review Team Act. | ||||||
15 | (m) Information provided to the predatory lending | ||||||
16 | database created pursuant to Article 3 of the Residential | ||||||
17 | Real Property Disclosure Act, except to the extent | ||||||
18 | authorized under that Article. | ||||||
19 | (n) Defense budgets and petitions for certification of | ||||||
20 | compensation and expenses for court appointed trial | ||||||
21 | counsel as provided under Sections 10 and 15 of the Capital | ||||||
22 | Crimes Litigation Act. This subsection (n) shall apply | ||||||
23 | until the conclusion of the trial of the case, even if the | ||||||
24 | prosecution chooses not to pursue the death penalty prior | ||||||
25 | to trial or sentencing. | ||||||
26 | (o) Information that is prohibited from being |
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1 | disclosed under Section 4 of the Illinois Health and | ||||||
2 | Hazardous Substances Registry Act. | ||||||
3 | (p) Security portions of system safety program plans, | ||||||
4 | investigation reports, surveys, schedules, lists, data, or | ||||||
5 | information compiled, collected, or prepared by or for the | ||||||
6 | Regional Transportation Authority under Section 2.11 of | ||||||
7 | the Regional Transportation Authority Act or the St. Clair | ||||||
8 | County Transit District under the Bi-State Transit Safety | ||||||
9 | Act. | ||||||
10 | (q) Information prohibited from being disclosed by the | ||||||
11 | Personnel Record Records Review Act. | ||||||
12 | (r) Information prohibited from being disclosed by the | ||||||
13 | Illinois School Student Records Act. | ||||||
14 | (s) Information the disclosure of which is restricted | ||||||
15 | under Section 5-108 of the Public Utilities Act.
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16 | (t) All identified or deidentified health information | ||||||
17 | in the form of health data or medical records contained in, | ||||||
18 | stored in, submitted to, transferred by, or released from | ||||||
19 | the Illinois Health Information Exchange, and identified | ||||||
20 | or deidentified health information in the form of health | ||||||
21 | data and medical records of the Illinois Health Information | ||||||
22 | Exchange in the possession of the Illinois Health | ||||||
23 | Information Exchange Authority due to its administration | ||||||
24 | of the Illinois Health Information Exchange. The terms | ||||||
25 | "identified" and "deidentified" shall be given the same | ||||||
26 | meaning as in the Health Insurance Portability and |
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1 | Accountability Act of 1996, Public Law 104-191, or any | ||||||
2 | subsequent amendments thereto, and any regulations | ||||||
3 | promulgated thereunder. | ||||||
4 | (u) Records and information provided to an independent | ||||||
5 | team of experts under the Developmental Disability and | ||||||
6 | Mental Health Safety Act (also known as Brian's Law ) . | ||||||
7 | (v) Names and information of people who have applied | ||||||
8 | for or received Firearm Owner's Identification Cards under | ||||||
9 | the Firearm Owners Identification Card Act or applied for | ||||||
10 | or received a concealed carry license under the Firearm | ||||||
11 | Concealed Carry Act, unless otherwise authorized by the | ||||||
12 | Firearm Concealed Carry Act; and databases under the | ||||||
13 | Firearm Concealed Carry Act, records of the Concealed Carry | ||||||
14 | Licensing Review Board under the Firearm Concealed Carry | ||||||
15 | Act, and law enforcement agency objections under the | ||||||
16 | Firearm Concealed Carry Act. | ||||||
17 | (w) Personally identifiable information which is | ||||||
18 | exempted from disclosure under subsection (g) of Section | ||||||
19 | 19.1 of the Toll Highway Act. | ||||||
20 | (x) Information which is exempted from disclosure | ||||||
21 | under Section 5-1014.3 of the Counties Code or Section | ||||||
22 | 8-11-21 of the Illinois Municipal Code. | ||||||
23 | (y) Confidential information under the Adult | ||||||
24 | Protective Services Act and its predecessor enabling | ||||||
25 | statute, the Elder Abuse and Neglect Act, including | ||||||
26 | information about the identity and administrative finding |
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1 | against any caregiver of a verified and substantiated | ||||||
2 | decision of abuse, neglect, or financial exploitation of an | ||||||
3 | eligible adult maintained in the Registry established | ||||||
4 | under Section 7.5 of the Adult Protective Services Act. | ||||||
5 | (z) Records and information provided to a fatality | ||||||
6 | review team or the Illinois Fatality Review Team Advisory | ||||||
7 | Council under Section 15 of the Adult Protective Services | ||||||
8 | Act. | ||||||
9 | (aa) Information which is exempted from disclosure | ||||||
10 | under Section 2.37 of the Wildlife Code. | ||||||
11 | (bb) Information which is or was prohibited from | ||||||
12 | disclosure by the Juvenile Court Act of 1987. | ||||||
13 | (cc) Recordings made under the Law Enforcement | ||||||
14 | Officer-Worn Body Camera Act, except to the extent | ||||||
15 | authorized under that Act. | ||||||
16 | (dd) Information that is prohibited from being | ||||||
17 | disclosed under Section 45 of the Condominium and Common | ||||||
18 | Interest Community Ombudsperson Act. | ||||||
19 | (ee) Information that is exempted from disclosure | ||||||
20 | under Section 30.1 of the Pharmacy Practice Act. | ||||||
21 | (ff) Information that is exempted from disclosure | ||||||
22 | under the Revised Uniform Unclaimed Property Act. | ||||||
23 | (gg) Information that is prohibited from being | ||||||
24 | disclosed under Section 7-603.5 of the Illinois Vehicle | ||||||
25 | Code. | ||||||
26 | (hh) Records that are exempt from disclosure under |
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1 | Section 1A-16.7 of the Election Code. | ||||||
2 | (ii) Information which is exempted from disclosure | ||||||
3 | under Section 2505-800 of the Department of Revenue Law of | ||||||
4 | the Civil Administrative Code of Illinois. | ||||||
5 | (jj) Information and reports that are required to be | ||||||
6 | submitted to the Department of Labor by registering day and | ||||||
7 | temporary labor service agencies but are exempt from | ||||||
8 | disclosure under subsection (a-1) of Section 45 of the Day | ||||||
9 | and Temporary Labor Services Act. | ||||||
10 | (kk) Information prohibited from disclosure under the | ||||||
11 | Seizure and Forfeiture Reporting Act. | ||||||
12 | (ll) Information the disclosure of which is restricted | ||||||
13 | and exempted under Section 5-30.8 of the Illinois Public | ||||||
14 | Aid Code. | ||||||
15 | (mm) (ll) Records that are exempt from disclosure under | ||||||
16 | Section 4.2 of the Crime Victims Compensation Act. | ||||||
17 | (nn) (ll) Information that is exempt from disclosure | ||||||
18 | under Section 70 of the Higher Education Student Assistance | ||||||
19 | Act. | ||||||
20 | (oo) Information that is exempt from disclosure under | ||||||
21 | subsection (j) of Section 5-36 of the Illinois Public Aid | ||||||
22 | Code. | ||||||
23 | (Source: P.A. 99-78, eff. 7-20-15; 99-298, eff. 8-6-15; 99-352, | ||||||
24 | eff. 1-1-16; 99-642, eff. 7-28-16; 99-776, eff. 8-12-16; | ||||||
25 | 99-863, eff. 8-19-16; 100-20, eff. 7-1-17; 100-22, eff. 1-1-18; | ||||||
26 | 100-201, eff. 8-18-17; 100-373, eff. 1-1-18; 100-464, eff. |
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1 | 8-28-17; 100-465, eff. 8-31-17; 100-512, eff. 7-1-18; 100-517, | ||||||
2 | eff. 6-1-18; 100-646, eff. 7-27-18; 100-690, eff. 1-1-19; | ||||||
3 | 100-863, eff. 8-14-18; 100-887, eff. 8-14-18; revised | ||||||
4 | 10-12-18.)
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5 | Section 5. The State Employees Group Insurance Act of 1971 | ||||||
6 | is amended by changing Section 6.11 as follows:
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7 | (5 ILCS 375/6.11)
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8 | Sec. 6.11. Required health benefits; Illinois Insurance | ||||||
9 | Code
requirements. The program of health
benefits shall provide | ||||||
10 | the post-mastectomy care benefits required to be covered
by a | ||||||
11 | policy of accident and health insurance under Section 356t of | ||||||
12 | the Illinois
Insurance Code. The program of health benefits | ||||||
13 | shall provide the coverage
required under Sections 356g, | ||||||
14 | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, | ||||||
15 | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, | ||||||
16 | 356z.14, 356z.15, 356z.17, 356z.22, 356z.25, and 356z.26, and | ||||||
17 | 356z.29 , and 356z.32 of the
Illinois Insurance Code.
The | ||||||
18 | program of health benefits must comply with Sections 155.22a, | ||||||
19 | 155.37, 355b, 356z.19, 370c, and 370c.1 , and Article XXXIIB of | ||||||
20 | the
Illinois Insurance Code. The Department of Insurance shall | ||||||
21 | enforce the requirements of this Section.
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22 | Rulemaking authority to implement Public Act 95-1045, if | ||||||
23 | any, is conditioned on the rules being adopted in accordance | ||||||
24 | with all provisions of the Illinois Administrative Procedure |
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1 | Act and all rules and procedures of the Joint Committee on | ||||||
2 | Administrative Rules; any purported rule not so adopted, for | ||||||
3 | whatever reason, is unauthorized. | ||||||
4 | (Source: P.A. 99-480, eff. 9-9-15; 100-24, eff. 7-18-17; | ||||||
5 | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1024, eff. | ||||||
6 | 1-1-19; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | ||||||
7 | 10-3-18.)
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8 | Section 10. The Illinois Insurance Code is amended by | ||||||
9 | adding Article XXXIIB as follows:
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10 | (215 ILCS 5/Art. XXXIIB heading new) | ||||||
11 | ARTICLE XXXIIB. PHARMACY BENEFIT MANAGERS | ||||||
12 | (215 ILCS 5/513b1 new) | ||||||
13 | Sec. 513b1. Pharmacy benefit manager contracts. | ||||||
14 | (a) As used in this Section: | ||||||
15 | "Maximum allowable cost" means the per-unit amount that a | ||||||
16 | pharmacy benefit manager reimburses a pharmacist for a | ||||||
17 | prescription drug, excluding dispensing fees, prior to the | ||||||
18 | application of copayments, coinsurance, and other cost-sharing | ||||||
19 | charges, if any. | ||||||
20 | "Pharmacy benefit manager" means a person, business, or | ||||||
21 | entity, including a wholly or partially owned or controlled | ||||||
22 | subsidiary of a pharmacy benefit manager, that provides claims | ||||||
23 | processing services or other prescription drug or device |
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1 | services, or both, for health benefit plans. | ||||||
2 | (b) A contract between a health insurer and a pharmacy | ||||||
3 | benefit manager must require that the pharmacy benefit manager: | ||||||
4 | (1) Update maximum allowable cost pricing information | ||||||
5 | at least every 7 calendar days. | ||||||
6 | (2) Maintain a process that will, in a timely manner, | ||||||
7 | eliminate drugs from maximum allowable cost lists or modify | ||||||
8 | drug prices to remain consistent with changes in pricing | ||||||
9 | data used in formulating maximum allowable cost prices and | ||||||
10 | product availability. | ||||||
11 | (c) In order to place a particular prescription drug on a | ||||||
12 | maximum allowable cost list, the pharmacy benefit manager must, | ||||||
13 | at a minimum, ensure that: | ||||||
14 | (1) The drug must have at least 3 or more nationally | ||||||
15 | available, therapeutically equivalent, multiple source | ||||||
16 | generic drugs with a significant cost difference. | ||||||
17 | (2) The products must be listed as therapeutically and | ||||||
18 | pharmaceutically equivalent or "A" or "AB" rated in the | ||||||
19 | Food and Drug Administration's most recent version of the | ||||||
20 | "Orange Book." | ||||||
21 | (3) The product must be available for purchase without | ||||||
22 | limitations by all pharmacies in the State from national or | ||||||
23 | regional wholesalers and not obsolete or temporarily | ||||||
24 | unavailable. | ||||||
25 | (d) A contract between a health insurer and a pharmacy | ||||||
26 | benefit manager must prohibit the pharmacy benefit manager from |
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1 | limiting a pharmacist's ability to disclose whether the | ||||||
2 | cost-sharing obligation exceeds the retail price for a covered | ||||||
3 | prescription drug, and the availability of a more affordable | ||||||
4 | alternative drug, in accordance with Section 42 of the Pharmacy | ||||||
5 | Practice Act. | ||||||
6 | (e) A contract between a health insurer and a pharmacy | ||||||
7 | benefit manager must prohibit the pharmacy benefit manager from | ||||||
8 | requiring an insured to make a payment for a prescription drug | ||||||
9 | at the point of sale in an amount that exceeds the lesser of: | ||||||
10 | (1) the applicable cost-sharing amount; or | ||||||
11 | (2) the retail price of the drug in the absence of | ||||||
12 | prescription drug coverage. | ||||||
13 | (f) This Section applies to contracts entered into or | ||||||
14 | renewed on or after July 1, 2020. | ||||||
15 | (g) This Section applies to any group or individual policy | ||||||
16 | of accident and health insurance or managed care plan that | ||||||
17 | provides coverage for prescription drugs and that is amended, | ||||||
18 | delivered, issued, or renewed on or after July 1, 2020.
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19 | (215 ILCS 5/513b2 new) | ||||||
20 | Sec. 513b2. Licensure requirements. | ||||||
21 | (a) Beginning on July 1, 2020, to conduct business in this | ||||||
22 | State, a pharmacy benefit manager must register with the | ||||||
23 | Director. To initially register or renew a registration, a | ||||||
24 | pharmacy benefit manager shall submit: | ||||||
25 | (1) A nonrefundable fee not to exceed $500. |
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1 | (2) A copy of the registrant's corporate charter, | ||||||
2 | articles of incorporation, or other charter document. | ||||||
3 | (3) A completed registration form adopted by the | ||||||
4 | Director containing: | ||||||
5 | (A) The name and address of the registrant. | ||||||
6 | (B) The name, address, and official position of | ||||||
7 | each officer and director of the registrant. | ||||||
8 | (b) The registrant shall report any change in information | ||||||
9 | required under this Section to the Director in writing within | ||||||
10 | 60 days after the change occurs. | ||||||
11 | (c) Upon receipt of a completed registration form, the | ||||||
12 | required documents, and the registration fee, the Director | ||||||
13 | shall issue a registration certificate. The certificate may be | ||||||
14 | in paper or electronic form, and shall clearly indicate the | ||||||
15 | expiration date of the registration. Registration certificates | ||||||
16 | are nontransferable. | ||||||
17 | (d) A registration certificate is valid for 2 years after | ||||||
18 | its date of issue. The Director shall adopt by rule an initial | ||||||
19 | registration fee not to exceed $500 and a registration renewal | ||||||
20 | fee not to exceed $500, both of which shall be nonrefundable. | ||||||
21 | Total fees may not exceed the cost of administering this | ||||||
22 | Section. | ||||||
23 | (e) The Department shall adopt any rules necessary to | ||||||
24 | implement this Section.
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25 | (215 ILCS 5/513b3 new) |
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1 | Sec. 513b3. Examination. | ||||||
2 | (a) The Director, or his or her designee, may examine a | ||||||
3 | registered pharmacy benefit manager. | ||||||
4 | (b) Any pharmacy benefit manager being examined shall | ||||||
5 | provide to the Director, or his or her designee, convenient and | ||||||
6 | free access to all books, records, documents, and other papers | ||||||
7 | relating to such pharmacy benefit manager's business affairs at | ||||||
8 | all reasonable hours at its offices. | ||||||
9 | (c) The Director, or his or her designee, may administer | ||||||
10 | oaths and thereafter examine any individual about the business | ||||||
11 | of the pharmacy benefit manager. | ||||||
12 | (d) The examiners designated by the Director under this | ||||||
13 | Section may make reports to the Director. Any report alleging | ||||||
14 | substantive violations of this Article, any applicable | ||||||
15 | provisions of this Code, or any applicable Part of Title 50 of | ||||||
16 | the Illinois Administrative Code shall be in writing and be | ||||||
17 | based upon facts obtained by the examiners. The report shall be | ||||||
18 | verified by the examiners. | ||||||
19 | (e) If a report is made, the Director shall either deliver | ||||||
20 | a duplicate report to the pharmacy benefit manager being | ||||||
21 | examined or send such duplicate by certified or registered mail | ||||||
22 | to the pharmacy benefit manager's address specified in the | ||||||
23 | records of the Department. The Director shall afford the | ||||||
24 | pharmacy benefit manager an opportunity to request a hearing to | ||||||
25 | object to the report. The pharmacy benefit manager may request | ||||||
26 | a hearing within 30 days after receipt of the duplicate report |
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1 | by giving the Director written notice of such request together | ||||||
2 | with written objections to the report. Any hearing shall be | ||||||
3 | conducted in accordance with Sections 402 and 403 of this Code. | ||||||
4 | The right to a hearing is waived if the delivery of the report | ||||||
5 | is refused or the report is otherwise undeliverable or the | ||||||
6 | pharmacy benefit manager does not timely request a hearing. | ||||||
7 | After the hearing or upon expiration of the time period during | ||||||
8 | which a pharmacy benefit manager may request a hearing, if the | ||||||
9 | examination reveals that the pharmacy benefit manager is | ||||||
10 | operating in violation of any applicable provision of this | ||||||
11 | Code, any applicable Part of Title 50 of the Illinois | ||||||
12 | Administrative Code, a provision of this Article, or prior | ||||||
13 | order, the Director, in the written order, may require the | ||||||
14 | pharmacy benefit manager to take any action the Director | ||||||
15 | considers necessary or appropriate in accordance with the | ||||||
16 | report or examination hearing. If the Director issues an order, | ||||||
17 | it shall be issued within 90 days after the report is filed, or | ||||||
18 | if there is a hearing, within 90 days after the conclusion of | ||||||
19 | the hearing. The order is subject to review under the | ||||||
20 | Administrative Review Law.
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21 | (215 ILCS 5/513b4 new) | ||||||
22 | Sec. 513b4. Administrative fine. | ||||||
23 | (a) If the Director finds that one or more grounds exist | ||||||
24 | for the revocation or suspension of a registration issued under | ||||||
25 | this Article, the Director may, in lieu of or in addition to |
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1 | such suspension or revocation, impose a fine upon the pharmacy | ||||||
2 | benefit manager as provided under subsection (b). | ||||||
3 | (b) With respect to any knowing and willful violation of a | ||||||
4 | lawful order of the Director, any applicable portion of this | ||||||
5 | Code, Part of Title 50 of the Illinois Administrative Code, or | ||||||
6 | provision of this Article, the Director may impose a fine upon | ||||||
7 | the pharmacy benefit manager in an amount not to exceed $50,000 | ||||||
8 | for each violation.
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9 | (215 ILCS 5/513b5 new) | ||||||
10 | Sec. 513b5. Failure to register. Any pharmacy benefit | ||||||
11 | manager that operates without a registration or fails to | ||||||
12 | register with the Director and pay the fee prescribed by this | ||||||
13 | Article is an unauthorized insurer as defined in Article VII of | ||||||
14 | this Code and shall be subject to all penalties provided for | ||||||
15 | therein.
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16 | (215 ILCS 5/513b6 new) | ||||||
17 | Sec. 513b6. Insurance Producer Administration Fund. All | ||||||
18 | fees and fines paid to and collected by the Director under this | ||||||
19 | Article shall be paid promptly after receipt thereof, together | ||||||
20 | with a detailed statement of such fees, into the Insurance | ||||||
21 | Producer Administration Fund. The moneys deposited into the | ||||||
22 | Insurance Producer Administration Fund may be transferred to | ||||||
23 | the Professions Indirect Cost Fund, as authorized under Section | ||||||
24 | 2105-300 of the Department of Professional Regulation Law of |
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1 | the Civil Administrative Code of Illinois.
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2 | Section 15. The Health Maintenance Organization Act is | ||||||
3 | amended by changing Section 5-3 as follows:
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4 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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5 | Sec. 5-3. Insurance Code provisions.
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6 | (a) Health Maintenance Organizations
shall be subject to | ||||||
7 | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
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8 | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, | ||||||
9 | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, | ||||||
10 | 355b, 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, | ||||||
11 | 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, | ||||||
12 | 356z.13, 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, | ||||||
13 | 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 364, | ||||||
14 | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, | ||||||
15 | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, | ||||||
16 | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, | ||||||
17 | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, | ||||||
18 | and XXVI , and XXXIIB of the Illinois Insurance Code.
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19 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
20 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
21 | Maintenance Organizations in
the following categories are | ||||||
22 | deemed to be "domestic companies":
| ||||||
23 | (1) a corporation authorized under the
Dental Service | ||||||
24 | Plan Act or the Voluntary Health Services Plans Act;
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1 | (2) a corporation organized under the laws of this | ||||||
2 | State; or
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3 | (3) a corporation organized under the laws of another | ||||||
4 | state, 30% or more
of the enrollees of which are residents | ||||||
5 | of this State, except a
corporation subject to | ||||||
6 | substantially the same requirements in its state of
| ||||||
7 | organization as is a "domestic company" under Article VIII | ||||||
8 | 1/2 of the
Illinois Insurance Code.
| ||||||
9 | (c) In considering the merger, consolidation, or other | ||||||
10 | acquisition of
control of a Health Maintenance Organization | ||||||
11 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
12 | (1) the Director shall give primary consideration to | ||||||
13 | the continuation of
benefits to enrollees and the financial | ||||||
14 | conditions of the acquired Health
Maintenance Organization | ||||||
15 | after the merger, consolidation, or other
acquisition of | ||||||
16 | control takes effect;
| ||||||
17 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
18 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
19 | apply and (ii) the Director, in making
his determination | ||||||
20 | with respect to the merger, consolidation, or other
| ||||||
21 | acquisition of control, need not take into account the | ||||||
22 | effect on
competition of the merger, consolidation, or | ||||||
23 | other acquisition of control;
| ||||||
24 | (3) the Director shall have the power to require the | ||||||
25 | following
information:
| ||||||
26 | (A) certification by an independent actuary of the |
| |||||||
| |||||||
1 | adequacy
of the reserves of the Health Maintenance | ||||||
2 | Organization sought to be acquired;
| ||||||
3 | (B) pro forma financial statements reflecting the | ||||||
4 | combined balance
sheets of the acquiring company and | ||||||
5 | the Health Maintenance Organization sought
to be | ||||||
6 | acquired as of the end of the preceding year and as of | ||||||
7 | a date 90 days
prior to the acquisition, as well as pro | ||||||
8 | forma financial statements
reflecting projected | ||||||
9 | combined operation for a period of 2 years;
| ||||||
10 | (C) a pro forma business plan detailing an | ||||||
11 | acquiring party's plans with
respect to the operation | ||||||
12 | of the Health Maintenance Organization sought to
be | ||||||
13 | acquired for a period of not less than 3 years; and
| ||||||
14 | (D) such other information as the Director shall | ||||||
15 | require.
| ||||||
16 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
17 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
18 | any health maintenance
organization of greater than 10% of its
| ||||||
19 | enrollee population (including without limitation the health | ||||||
20 | maintenance
organization's right, title, and interest in and to | ||||||
21 | its health care
certificates).
| ||||||
22 | (e) In considering any management contract or service | ||||||
23 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
24 | Code, the Director (i) shall, in
addition to the criteria | ||||||
25 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
26 | into account the effect of the management contract or
service |
| |||||||
| |||||||
1 | agreement on the continuation of benefits to enrollees and the
| ||||||
2 | financial condition of the health maintenance organization to | ||||||
3 | be managed or
serviced, and (ii) need not take into account the | ||||||
4 | effect of the management
contract or service agreement on | ||||||
5 | competition.
| ||||||
6 | (f) Except for small employer groups as defined in the | ||||||
7 | Small Employer
Rating, Renewability and Portability Health | ||||||
8 | Insurance Act and except for
medicare supplement policies as | ||||||
9 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
10 | Maintenance Organization may by contract agree with a
group or | ||||||
11 | other enrollment unit to effect refunds or charge additional | ||||||
12 | premiums
under the following terms and conditions:
| ||||||
13 | (i) the amount of, and other terms and conditions with | ||||||
14 | respect to, the
refund or additional premium are set forth | ||||||
15 | in the group or enrollment unit
contract agreed in advance | ||||||
16 | of the period for which a refund is to be paid or
| ||||||
17 | additional premium is to be charged (which period shall not | ||||||
18 | be less than one
year); and
| ||||||
19 | (ii) the amount of the refund or additional premium | ||||||
20 | shall not exceed 20%
of the Health Maintenance | ||||||
21 | Organization's profitable or unprofitable experience
with | ||||||
22 | respect to the group or other enrollment unit for the | ||||||
23 | period (and, for
purposes of a refund or additional | ||||||
24 | premium, the profitable or unprofitable
experience shall | ||||||
25 | be calculated taking into account a pro rata share of the
| ||||||
26 | Health Maintenance Organization's administrative and |
| |||||||
| |||||||
1 | marketing expenses, but
shall not include any refund to be | ||||||
2 | made or additional premium to be paid
pursuant to this | ||||||
3 | subsection (f)). The Health Maintenance Organization and | ||||||
4 | the
group or enrollment unit may agree that the profitable | ||||||
5 | or unprofitable
experience may be calculated taking into | ||||||
6 | account the refund period and the
immediately preceding 2 | ||||||
7 | plan years.
| ||||||
8 | The Health Maintenance Organization shall include a | ||||||
9 | statement in the
evidence of coverage issued to each enrollee | ||||||
10 | describing the possibility of a
refund or additional premium, | ||||||
11 | and upon request of any group or enrollment unit,
provide to | ||||||
12 | the group or enrollment unit a description of the method used | ||||||
13 | to
calculate (1) the Health Maintenance Organization's | ||||||
14 | profitable experience with
respect to the group or enrollment | ||||||
15 | unit and the resulting refund to the group
or enrollment unit | ||||||
16 | or (2) the Health Maintenance Organization's unprofitable
| ||||||
17 | experience with respect to the group or enrollment unit and the | ||||||
18 | resulting
additional premium to be paid by the group or | ||||||
19 | enrollment unit.
| ||||||
20 | In no event shall the Illinois Health Maintenance | ||||||
21 | Organization
Guaranty Association be liable to pay any | ||||||
22 | contractual obligation of an
insolvent organization to pay any | ||||||
23 | refund authorized under this Section.
| ||||||
24 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
25 | if any, is conditioned on the rules being adopted in accordance | ||||||
26 | with all provisions of the Illinois Administrative Procedure |
| |||||||
| |||||||
1 | Act and all rules and procedures of the Joint Committee on | ||||||
2 | Administrative Rules; any purported rule not so adopted, for | ||||||
3 | whatever reason, is unauthorized. | ||||||
4 | (Source: P.A. 99-761, eff. 1-1-18; 100-24, eff. 7-18-17; | ||||||
5 | 100-138, eff. 8-18-17; 100-863, eff. 8-14-18; 100-1026, eff. | ||||||
6 | 8-22-18; 100-1057, eff. 1-1-19; 100-1102, eff. 1-1-19; revised | ||||||
7 | 10-4-18.)
| ||||||
8 | Section 20. The Managed Care Reform and Patient Rights Act | ||||||
9 | is amended by changing Sections 30 and 65 as follows:
| ||||||
10 | (215 ILCS 134/30)
| ||||||
11 | Sec. 30. Prohibitions.
| ||||||
12 | (a) No health care plan or its subcontractors may prohibit | ||||||
13 | or discourage
health care providers
by contract or policy from
| ||||||
14 | discussing any health care services and health care providers, | ||||||
15 | utilization
review and quality assurance policies, terms and | ||||||
16 | conditions of plans and plan
policy with enrollees, prospective | ||||||
17 | enrollees, providers, or the public.
| ||||||
18 | (b) No health care plan by contract, written policy, or | ||||||
19 | procedure may
permit or allow an individual or entity to | ||||||
20 | dispense a different
drug in place of the drug or brand of drug | ||||||
21 | ordered or prescribed without the
express permission of the | ||||||
22 | person ordering or prescribing the drug, except as
provided | ||||||
23 | under Section 3.14 of the Illinois Food, Drug and Cosmetic Act.
| ||||||
24 | (c) No health care plan or its subcontractors may by |
| |||||||
| |||||||
1 | contract, written
policy, procedure, or otherwise mandate or | ||||||
2 | require an enrollee
to substitute his or her participating | ||||||
3 | primary care physician
under the plan during inpatient | ||||||
4 | hospitalization, such as with a hospitalist physician licensed | ||||||
5 | to practice medicine in all its branches,
without the agreement | ||||||
6 | of that enrollee's
participating primary care physician. | ||||||
7 | "Participating primary care
physician" for health care plans | ||||||
8 | and subcontractors that do not require
coordination of care by | ||||||
9 | a primary care physician means the participating
physician | ||||||
10 | treating the patient. All health care plans shall inform | ||||||
11 | enrollees
of any policies, recommendations, or guidelines | ||||||
12 | concerning the
substitution of the enrollee's primary care | ||||||
13 | physician when hospitalization is
necessary in the manner set | ||||||
14 | forth in subsections (d) and (e) of Section 15.
| ||||||
15 | (d) A health care plan shall apply any third-party | ||||||
16 | payments, financial assistance, discount, product vouchers, or | ||||||
17 | any other reduction in out-of-pocket expenses made by or on | ||||||
18 | behalf of such insured for prescription drugs toward a covered | ||||||
19 | individual's deductible, copay, or cost-sharing | ||||||
20 | responsibility, or out-of-pocket maximum associated with the | ||||||
21 | individual's health insurance. | ||||||
22 | (e) (d) Any violation of this Section shall be subject to | ||||||
23 | the
penalties under this Act.
| ||||||
24 | (Source: P.A. 94-866, eff. 6-16-06.)
| ||||||
25 | (215 ILCS 134/65)
|
| |||||||
| |||||||
1 | Sec. 65. Emergency services prior to stabilization.
| ||||||
2 | (a) A health care plan
that provides or that is required by | ||||||
3 | law to provide coverage for emergency
services shall provide | ||||||
4 | coverage such that payment under this coverage is not
dependent | ||||||
5 | upon whether the services are performed by a plan or non-plan | ||||||
6 | health
care provider and without regard to prior authorization. | ||||||
7 | This coverage shall be
at the same benefit level as if the | ||||||
8 | services or treatment had been rendered by
the health care plan | ||||||
9 | physician licensed to practice medicine in all
its branches or | ||||||
10 | health care provider.
| ||||||
11 | (b) Prior authorization or approval by the plan shall not | ||||||
12 | be required for
emergency services.
| ||||||
13 | (c) Coverage and payment shall only be retrospectively | ||||||
14 | denied under the
following circumstances:
| ||||||
15 | (1) upon reasonable determination that the emergency | ||||||
16 | services claimed were
never performed;
| ||||||
17 | (2) upon timely determination that the emergency | ||||||
18 | evaluation and treatment
were
rendered to an enrollee who | ||||||
19 | sought emergency services and whose circumstance
did not | ||||||
20 | meet the definition of emergency medical condition; any | ||||||
21 | denial under this paragraph (2) shall be based on the | ||||||
22 | prudent layperson standard at the time the enrollee first | ||||||
23 | sought emergency evaluation and treatment for his or her | ||||||
24 | symptoms; insurers are prohibited from denying claims | ||||||
25 | under this paragraph (2) based on the use of diagnosis or | ||||||
26 | procedure codes;
|
| |||||||
| |||||||
1 | (3) upon determination that the patient receiving such | ||||||
2 | services was not an
enrollee of the health care plan; or
| ||||||
3 | (4) upon material misrepresentation by the enrollee or | ||||||
4 | health care
provider; "material" means a fact or situation | ||||||
5 | that is not merely technical in
nature and results or could | ||||||
6 | result in a substantial change in the situation.
| ||||||
7 | (d) When an enrollee presents to a hospital seeking | ||||||
8 | emergency services,
the determination as to whether the need | ||||||
9 | for those
services exists shall be made for purposes of | ||||||
10 | treatment by a
physician licensed to practice medicine in all | ||||||
11 | its branches or, to the extent
permitted by applicable law, by | ||||||
12 | other appropriately licensed
personnel under the supervision | ||||||
13 | of
or in collaboration with a physician licensed to practice | ||||||
14 | medicine in all its
branches.
The physician or other
| ||||||
15 | appropriate personnel shall indicate in the patient's chart the | ||||||
16 | results of the
emergency medical screening examination.
| ||||||
17 | (e) The appropriate use of the 911 emergency telephone | ||||||
18 | system or its local
equivalent shall not be discouraged or | ||||||
19 | penalized by the health care plan when
an emergency medical | ||||||
20 | condition exists.
This provision shall not imply that the use | ||||||
21 | of 911 or its local equivalent is a
factor in determining the | ||||||
22 | existence of an emergency medical condition.
| ||||||
23 | (f) The medical director's or his or her designee's
| ||||||
24 | determination of whether the enrollee meets the standard of an | ||||||
25 | emergency
medical condition shall be based solely upon the | ||||||
26 | presenting symptoms documented
in the medical record at the |
| |||||||
| |||||||
1 | time care was
sought.
Only a clinical peer may make an adverse | ||||||
2 | determination.
| ||||||
3 | (g) Nothing in this Section shall prohibit the imposition | ||||||
4 | of deductibles,
copayments, and co-insurance.
Nothing in this | ||||||
5 | Section alters the prohibition on billing enrollees contained
| ||||||
6 | in the Health Maintenance Organization Act.
| ||||||
7 | (Source: P.A. 91-617, eff. 1-1-00.)
| ||||||
8 | Section 25. The Pharmacy Practice Act is amended by adding | ||||||
9 | Section 42 as follows:
| ||||||
10 | (225 ILCS 85/42 new) | ||||||
11 | Sec. 42. Information disclosure. A pharmacist or her or his | ||||||
12 | authorized employee must inform customers of a less expensive, | ||||||
13 | generically equivalent drug product for her or his prescription | ||||||
14 | and whether the cost-sharing obligation to the customer exceeds | ||||||
15 | the retail price of the prescription in the absence of | ||||||
16 | prescription drug coverage.
| ||||||
17 | Section 30. The Illinois Public Aid Code is amended by | ||||||
18 | adding Section 5-36 as follows:
| ||||||
19 | (305 ILCS 5/5-36 new) | ||||||
20 | Sec. 5-36. Pharmacy benefits. | ||||||
21 | (a)(1) The Department may enter into a contract with any | ||||||
22 | third party on a fee-for-service reimbursement model for the |
| |||||||
| |||||||
1 | purpose of administering pharmacy benefits as provided in this | ||||||
2 | Section; however, these services shall be approved by the | ||||||
3 | Department. The Department shall ensure coordination of care | ||||||
4 | between the third-party administrator and managed care | ||||||
5 | organizations as a consideration in any contracts established | ||||||
6 | in accordance with this Section. Any managed care techniques, | ||||||
7 | principles, or administration of benefits utilized in | ||||||
8 | accordance with this subsection shall comply with State law. | ||||||
9 | (2) The following shall apply to contracts between entities | ||||||
10 | contracting relating to third-party administrators and | ||||||
11 | pharmacies: | ||||||
12 | (A) the Department shall approve any contract between a | ||||||
13 | third-party administrator and a pharmacy; | ||||||
14 | (B) a third-party administrator shall not change the | ||||||
15 | terms of a contract between a third-party administrator and | ||||||
16 | a pharmacy without written approval by the Department; and | ||||||
17 | (C) a third-party administrator shall not create, | ||||||
18 | modify, implement, or indirectly establish any fee on a | ||||||
19 | pharmacy, pharmacist, or a recipient of medical assistance | ||||||
20 | without written approval by the Department. | ||||||
21 | (b) The provisions of this Section shall not apply to | ||||||
22 | outpatient pharmacy services provided by a health care facility | ||||||
23 | registered as a covered entity pursuant to 42 U.S.C. 256b or | ||||||
24 | any pharmacy owned by or contracted with the covered entity. A | ||||||
25 | Medicaid managed care organization shall, either directly or | ||||||
26 | through a pharmacy benefit manager, administer and reimburse |
| |||||||
| |||||||
1 | outpatient pharmacy claims submitted by a health care facility | ||||||
2 | registered as a covered entity pursuant to 42 U.S.C. 256b, its | ||||||
3 | owned pharmacies, and contracted pharmacies in accordance with | ||||||
4 | the contractual agreements the Medicaid managed care | ||||||
5 | organization or its pharmacy benefit manager has with such | ||||||
6 | facilities and pharmacies. A Medicaid managed care | ||||||
7 | organization or its pharmacy benefit manager shall not exclude | ||||||
8 | any health care facility registered as a covered entity | ||||||
9 | pursuant to 42 U.S.C. 256b from its pharmacy network. Any | ||||||
10 | pharmacy benefit manager that contracts with a Medicaid managed | ||||||
11 | care organization to administer and reimburse outpatient | ||||||
12 | pharmacy claims as provided in this Section must be registered | ||||||
13 | with the Director of Insurance in accordance with Section 513b2 | ||||||
14 | of the Illinois Insurance Code. | ||||||
15 | (c) On at least an annual basis, the Director of the | ||||||
16 | Department of Healthcare and Family Services shall submit a | ||||||
17 | report beginning no later than one year after the effective | ||||||
18 | date of this amendatory Act of the 101st General Assembly to | ||||||
19 | the House and Senate Human Services Committees and the House | ||||||
20 | and Senate Financial Institutions Committees that provides an | ||||||
21 | update on any contract, contract issues, formulary, dispensing | ||||||
22 | fees, and maximum allowable cost concerns regarding a | ||||||
23 | third-party administrator and managed care. | ||||||
24 | (d) A pharmacy benefit manager shall notify the Department | ||||||
25 | in writing of any activity, policy, or practice of the pharmacy | ||||||
26 | benefit manager that directly or indirectly presents a conflict |
| |||||||
| |||||||
1 | of interest that interferes with the discharge of the pharmacy | ||||||
2 | benefit manager's duty to a managed care organization to | ||||||
3 | exercise its contractual duties. | ||||||
4 | (e) A pharmacy benefit manager shall, upon request, | ||||||
5 | disclose to the Department the following information: | ||||||
6 | (1) whether the pharmacy benefit manager has a | ||||||
7 | contract, agreement, or other arrangement with a | ||||||
8 | pharmaceutical manufacturer to exclusively dispense or | ||||||
9 | provide a drug to a managed care organization's enrollees, | ||||||
10 | and the application of all consideration or economic | ||||||
11 | benefits collected or received pursuant to that | ||||||
12 | arrangement; | ||||||
13 | (2) the percentage of claims payments made by the | ||||||
14 | pharmacy benefit manager to pharmacies owned, managed, or | ||||||
15 | controlled by the pharmacy benefit manager or any of the | ||||||
16 | pharmacy benefit manager's management companies, parent | ||||||
17 | companies, subsidiary companies, jointly held companies, | ||||||
18 | or companies otherwise affiliated by a common owner, | ||||||
19 | manager, or holding company for the previous year; | ||||||
20 | (3) the aggregate amount of the fees or assessments | ||||||
21 | imposed on, or collected from, pharmacy providers; and | ||||||
22 | (4) the average annualized percentage of revenue | ||||||
23 | collected by the pharmacy benefit manager as a result of | ||||||
24 | each contract it has executed with a managed care | ||||||
25 | organization contracted by the Department to provide | ||||||
26 | medical assistance benefits which is not paid by the |
| |||||||
| |||||||
1 | pharmacy benefit manager to pharmacy providers and | ||||||
2 | pharmaceutical manufacturers or labelers or in order to | ||||||
3 | perform administrative functions pursuant to its contracts | ||||||
4 | with managed care organizations. | ||||||
5 | (f) The information disclosed under subsection (e) shall | ||||||
6 | include all retail, mail order, specialty, and compounded | ||||||
7 | prescription products. All information made
available to the | ||||||
8 | Department under subsection (e) is confidential and not subject | ||||||
9 | to disclosure under the Freedom of Information Act. | ||||||
10 | (g) A pharmacy benefit manager shall disclose directly in | ||||||
11 | writing to a pharmacy provider contracting with the pharmacy | ||||||
12 | benefit manager of any material change to a contract provision | ||||||
13 | that affects the terms of the reimbursement, the process for | ||||||
14 | verifying benefits and eligibility, dispute resolution, | ||||||
15 | procedures for verifying drugs included on the formulary, and | ||||||
16 | contract termination at least 30 days prior to the date of the | ||||||
17 | change to the provision. | ||||||
18 | (h) A pharmacy benefit manager shall not include the | ||||||
19 | following in a contract with a pharmacy provider: | ||||||
20 | (1) a provision prohibiting the provider from | ||||||
21 | informing a patient of a less costly alternative to a | ||||||
22 | prescribed medication; or | ||||||
23 | (2) a provision that prohibits the provider from | ||||||
24 | dispensing a particular amount of a prescribed medication, | ||||||
25 | if the pharmacy benefit manager allows that amount to be | ||||||
26 | dispensed through a pharmacy owned or controlled by the |
| |||||||
| |||||||
1 | pharmacy benefit manager, unless the prescription drug is | ||||||
2 | subject to restricted distribution by the United States | ||||||
3 | Food and Drug Administration or requires special handling, | ||||||
4 | provider coordination, or patient education that cannot be | ||||||
5 | provided by a retail pharmacy. | ||||||
6 | (i) Nothing in this Section shall be construed to prohibit | ||||||
7 | a pharmacy benefit manager from requiring the same | ||||||
8 | reimbursement and terms and conditions for a pharmacy provider | ||||||
9 | as for a pharmacy owned, controlled, or otherwise associated | ||||||
10 | with the pharmacy benefit manager. | ||||||
11 | (j) A pharmacy benefit manager shall establish and | ||||||
12 | implement a process for the resolution of disputes arising out | ||||||
13 | of this Section, which shall be approved by the Department. | ||||||
14 | (k) The Department shall adopt rules establishing | ||||||
15 | reasonable dispensing fees in accordance with guidance or | ||||||
16 | guidelines from the federal Centers for Medicare and Medicaid | ||||||
17 | Services.
| ||||||
18 | Section 97. Severability. If any provision of this Act or | ||||||
19 | the application of this Act to any person or circumstance is | ||||||
20 | held invalid, the invalidity shall not affect other provisions | ||||||
21 | or applications of this Act which can be given effect without | ||||||
22 | the invalid provision or application, and to this end, the | ||||||
23 | provisions of this Act are declared severable.".
|