Bill Text: IL HB4707 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Medical Assistance Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to impose a 4-prescription drug limit and prior authorization requirement under the medical assistance program.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2024-05-31 - Rule 19(a) / Re-referred to Rules Committee [HB4707 Detail]

Download: Illinois-2023-HB4707-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4707 Introduced , by Rep. Hoan Huynh SYNOPSIS AS INTRODUCED:
305 ILCS 5/5-5.12 from Ch. 23, par. 5-5.12
Amends the Medical Assistance Article of the Illinois Public Aid Code. Removes a provision requiring the Department of Healthcare and Family Services to impose a 4-prescription drug limit and prior authorization requirement under the medical assistance program.
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A BILL FOR
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AN ACT concerning public aid.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Public Aid Code is amended by
changing Section 5-5.12 as follows:
(305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
Sec. 5-5.12. Pharmacy payments.
(a) Every request submitted by a pharmacy for
reimbursement under this Article for prescription drugs
provided to a recipient of aid under this Article shall
include the name of the prescriber or an acceptable
identification number as established by the Department.
(b) Pharmacies providing prescription drugs under this
Article shall be reimbursed at a rate which shall include a
professional dispensing fee as determined by the Illinois
Department, plus the current acquisition cost of the
prescription drug dispensed. The Illinois Department shall
update its information on the acquisition costs of all
prescription drugs no less frequently than every 30 days.
However, the Illinois Department may set the rate of
reimbursement for the acquisition cost, by rule, at a
percentage of the current average wholesale acquisition cost.
(c) (Blank).

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(d) The Department shall review utilization of narcotic
medications in the medical assistance program and impose
utilization controls that protect against abuse.
(e) When making determinations as to which drugs shall be
on a prior approval list, the Department shall include as part
of the analysis for this determination, the degree to which a
drug may affect individuals in different ways based on factors
including the gender of the person taking the medication.
(f) The Department shall cooperate with the Department of
Public Health and the Department of Human Services Division of
Mental Health in identifying psychotropic medications that,
when given in a particular form, manner, duration, or
frequency (including "as needed") in a dosage, or in
conjunction with other psychotropic medications to a nursing
home resident or to a resident of a facility licensed under the
ID/DD Community Care Act or the MC/DD Act, may constitute a
chemical restraint or an "unnecessary drug" as defined by the
Nursing Home Care Act or Titles XVIII and XIX of the Social
Security Act and the implementing rules and regulations. The
Department shall require prior approval for any such
medication prescribed for a nursing home resident or to a
resident of a facility licensed under the ID/DD Community Care
Act or the MC/DD Act, that appears to be a chemical restraint
or an unnecessary drug. The Department shall consult with the
Department of Human Services Division of Mental Health in
developing a protocol and criteria for deciding whether to

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grant such prior approval.
(g) The Department may by rule provide for reimbursement
of the dispensing of a 90-day supply of a generic or brand
name, non-narcotic maintenance medication in circumstances
where it is cost effective.
(g-5) On and after July 1, 2012, the Department may
require the dispensing of drugs to nursing home residents be
in a 7-day supply or other amount less than a 31-day supply.
The Department shall pay only one dispensing fee per 31-day
supply.
(h) Effective July 1, 2011, the Department shall
discontinue coverage of select over-the-counter drugs,
including analgesics and cough and cold and allergy
medications.
(h-5) On and after July 1, 2012, the Department shall
impose utilization controls, including, but not limited to,
prior approval on specialty drugs, oncolytic drugs, drugs for
the treatment of HIV or AIDS, immunosuppressant drugs, and
biological products in order to maximize savings on these
drugs. The Department may adjust payment methodologies for
non-pharmacy billed drugs in order to incentivize the
selection of lower-cost drugs. For drugs for the treatment of
AIDS, the Department shall take into consideration the
potential for non-adherence by certain populations, and shall
develop protocols with organizations or providers primarily
serving those with HIV/AIDS, as long as such measures intend

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to maintain cost neutrality with other utilization management
controls such as prior approval. For hemophilia, the
Department shall develop a program of utilization review and
control which may include, in the discretion of the
Department, prior approvals. The Department may impose special
standards on providers that dispense blood factors which shall
include, in the discretion of the Department, staff training
and education; patient outreach and education; case
management; in-home patient assessments; assay management;
maintenance of stock; emergency dispensing timeframes; data
collection and reporting; dispensing of supplies related to
blood factor infusions; cold chain management and packaging
practices; care coordination; product recalls; and emergency
clinical consultation. The Department may require patients to
receive a comprehensive examination annually at an appropriate
provider in order to be eligible to continue to receive blood
factor.
(i) On and after July 1, 2012, the Department shall reduce
any rate of reimbursement for services or other payments or
alter any methodologies authorized by this Code to reduce any
rate of reimbursement for services or other payments in
accordance with Section 5-5e.
(j) (Blank). On and after July 1, 2012, the Department
shall impose limitations on prescription drugs such that the
Department shall not provide reimbursement for more than 4
prescriptions, including 3 brand name prescriptions, for

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distinct drugs in a 30-day period, unless prior approval is
received for all prescriptions in excess of the 4-prescription
limit. Drugs in the following therapeutic classes shall not be
subject to prior approval as a result of the 4-prescription
limit: immunosuppressant drugs, oncolytic drugs,
anti-retroviral drugs, and, on or after July 1, 2014,
antipsychotic drugs. On or after July 1, 2014, the Department
may exempt children with complex medical needs enrolled in a
care coordination entity contracted with the Department to
solely coordinate care for such children, if the Department
determines that the entity has a comprehensive drug
reconciliation program.
(k) No medication therapy management program implemented
by the Department shall be contrary to the provisions of the
Pharmacy Practice Act.
(l) Any provider enrolled with the Department that bills
the Department for outpatient drugs and is eligible to enroll
in the federal Drug Pricing Program under Section 340B of the
federal Public Health Service Act shall enroll in that
program. No entity participating in the federal Drug Pricing
Program under Section 340B of the federal Public Health
Service Act may exclude fee-for-service Medicaid from their
participation in that program, however, entities defined in
Section 1905(l)(2)(B) of the Social Security Act are excluded
from this requirement. This subsection does not apply to
outpatient drugs billed to Medicaid managed care

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