Bill Text: IL SB1618 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. Provides that no later than July 1, 2024, each health plan and pharmacy benefit manager operating in this State shall, upon request of a covered individual, his or her health care provider, or an authorized third party on his or her behalf, furnish specified cost, benefit, and coverage data to the covered individual, his or her health care provider, or the third party of his or her choosing and shall ensure that the data is: (1) current no later than one business day after any change is made; (2) provided in real time; and (3) in a format that is easily accessible to the covered individual or, in the case of his or her health care provider, through an electronic health records system. Provides that the format of the request shall use specified industry content and transport standards. Provides that a facsimile is not an acceptable electronic format. Provides that upon request, specified data shall be provided for any drug covered under the covered individual's health plan. Makes other changes. Defines terms.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2024-04-03 - Chief Sponsor Changed to Sen. Lakesia Collins [SB1618 Detail]

Download: Illinois-2023-SB1618-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 SB1618 Introduced 2/8/2023, by Sen. Julie A. Morrison SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.61 new
215 ILCS 5/513b7 new
Amends the Illinois Insurance Code. Provides that no later than July 1, 2024, each health plan and pharmacy benefit manager operating in this State shall, upon request of a covered individual, his or her health care provider, or an authorized third party on his or her behalf, furnish specified cost, benefit, and coverage data to the covered individual, his or her health care provider, or the third party of his or her choosing and shall ensure that the data is: (1) current no later than one business day after any change is made; (2) provided in real time; and (3) in a format that is easily accessible to the covered individual or, in the case of his or her health care provider, through an electronic health records system. Provides that the format of the request shall use specified industry content and transport standards. Provides that a facsimile is not an acceptable electronic format. Provides that upon request, specified data shall be provided for any drug covered under the covered individual's health plan. Makes other changes. Defines terms.
LRB103 29540 BMS 55935 b
A BILL FOR
SB1618 LRB103 29540 BMS 55935 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
adding Sections 356z.61 and 513b7 as follows:
(215 ILCS 5/356z.61 new)
Sec. 356z.61. Patient prescription pricing transparency.
(a) As used in this Section:
"Authorized third party" includes a third party legally
authorized under State or federal law subject to a Health
Insurance Portability and Accountability Act of 1996 business
associate agreement.
"Cost-sharing information" means the amount a covered
individual is required to pay to receive a drug that is covered
under the covered individual's health plan.
"Coverage" means those health care services to which a
covered individual is entitled under the terms of the health
plan.
"Electronic health record" means a digital version of a
patient's paper chart and medical history that makes
information available instantly and securely to authorized
users.
"Electronic prescribing system" means a system that

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enables prescribers to enter prescription information into a
computer prescription device and securely transmit the
prescription to pharmacies using a special software program
and connectivity to a transmission network.
"Prescriber" means a health care provider licensed to
prescribe medication or medical devices in this State.
"Real-time benefit tool" means an electronic prescription
decision support tool that (i) is capable of integrating with
prescribers' electronic prescribing and, if feasible,
electronic health record systems; and (ii) complies with the
technical standards adopted by an American National Standards
Institute accredited standards development organization.
(b) No later than July 1, 2024, each health plan operating
in this State shall, upon request of a covered individual, his
or her health care provider, or an authorized third party on
his or her behalf, furnish the cost, benefit, and coverage
data required under this Section to the covered individual,
his or her health care provider, or the third party of his or
her choosing and shall ensure that the data is:
(1) current no later than one business day after any
change is made;
(2) provided in real time; and
(3) in a format that is easily accessible to the
covered individual or, in the case of his or her health
care provider, through an electronic health records
system.

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(c) The format of the request shall use established
industry content and transport standards published by:
(1) a standards developing organization accredited by
the American National Standards Institute, including the
National Council for Prescription Drug Programs,
Accredited Standards Committee X12, and Health Level 7;
(2) a relevant federal or state governing body,
including the Centers for Medicare & Medicaid Services or
the Office of the National Coordinator for Health
Information Technology; or
(3) another format deemed acceptable to the Department
that provides the data described in subsection (a) and
with the same timeliness as required by this Section.
(d) A facsimile is not an acceptable electronic format
under this Section.
(e) Upon request, the following data shall be provided for
any drug covered under the covered individual's health plan:
(1) patient-specific eligibility information;
(2) patient-specific prescription cost and benefit
data, such as applicable formulary, benefit, coverage and
cost-sharing data for the prescribed drug, and clinically
appropriate alternatives, when appropriate;
(3) patient-specific cost-sharing information that
describes variance in cost sharing based on the pharmacy
dispensing the prescribed drug or its alternatives, and in
relation to the patient's benefit, such as spending

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related to the out-of-pocket maximum;
(4) information regarding lower cost clinically
appropriate treatment alternatives; and
(5) applicable utilization management requirements.
(f) Any health plan shall furnish the data as required
whether the request is made using the drug's unique billing
code, such as a National Drug Code or Healthcare Common
Procedure Coding System code, or descriptive term. A health
plan shall not deny or unreasonably delay a request as a method
of blocking the required data from being shared based on how
the drug was requested.
(g) A health plan shall not restrict, prohibit, or
otherwise hinder the prescriber from communicating or sharing
benefit and coverage information that reflects other choices,
such as cash price, lower cost clinically appropriate
alternatives, whether or not they are covered under the
covered individual's plan and support programs, and the cost
available at the patient's pharmacy of choice.
(h) A health plan shall not, except as may be required by
law, interfere with, prevent, or materially discourage access,
exchange, or use of the data as required, which may include
charging fees or not responding to a request for such data in a
reasonable time frame; nor penalize a health care provider or
professional for disclosing such information to a covered
individual or legally prescribing, administering, or ordering
a clinically appropriate or lower cost alternative.

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(i) Nothing in this Section shall be construed to limit
access to the most up-to-date patient-specific eligibility or
patient-specific prescription cost and benefit data by the
health plan.
(j) Nothing in this Section shall interfere with patient
choice and a health care professional's ability to convey the
full range of prescription drug cost options to a patient.
Health plans shall not restrict a health care professional
from communicating prescription cost options to the patient.
(k) No real-time benefit tool shall require a patient to
use specific plan-preferred drugs or pharmacies.
(215 ILCS 5/513b7 new)
Sec. 513b7. Patient prescription pricing transparency.
(a) No later than July 1, 2024, each pharmacy benefit
manager operating in this State shall, upon request of a
covered individual, his or her health care provider, or an
authorized third party on his or her behalf, furnish the cost,
benefit, and coverage data required under this Section to the
covered individual, his or her health care provider, or the
third party of his or her choosing and shall ensure that the
data is:
(1) current no later than one business day after any
change is made;
(2) provided in real time; and
(3) in a format that is easily accessible to the

SB1618 - 6 - LRB103 29540 BMS 55935 b
covered individual or, in the case of his or her health
care provider, through an electronic health records
system.
(b) The format of the request shall use established
industry content and transport standards published by:
(1) a standards developing organization accredited by
the American National Standards Institute, including the
National Council for Prescription Drug Programs,
Accredited Standards Committee X12, and Health Level 7;
(2) a relevant federal or state governing body,
including the Centers for Medicare & Medicaid Services or
the Office of the National Coordinator for Health
Information Technology; or
(3) another format deemed acceptable to the Department
that provides the data described in subsection (a) and
with the same timeliness as required by this Section.
(c) A facsimile is not an acceptable electronic format
under this Section.
(d) Upon request, the following data shall be provided for
any drug covered under the covered individual's health plan:
(1) patient-specific eligibility information;
(2) patient-specific prescription cost and benefit
data, such as applicable formulary, benefit, coverage and
cost-sharing data for the prescribed drug, and clinically
appropriate alternatives, when appropriate;
(3) patient-specific cost-sharing information that

SB1618 - 7 - LRB103 29540 BMS 55935 b
describes variance in cost sharing based on the pharmacy
dispensing the prescribed drug or its alternatives, and in
relation to the patient's benefit, such as spending
related to the out-of-pocket maximum;
(4) information regarding lower cost clinically
appropriate treatment alternatives; and
(5) applicable utilization management requirements.
(e) A pharmacy benefit manager shall furnish the data as
required whether the request is made using the drug's unique
billing code, such as a National Drug Code or Healthcare
Common Procedure Coding System code, or descriptive term. A
pharmacy benefit manager shall not deny or unreasonably delay
a request as a method of blocking the required data from being
shared based on how the drug was requested.
(f) A pharmacy benefit manager shall not restrict,
prohibit, or otherwise hinder the prescriber from
communicating or sharing benefit and coverage information that
reflects other choices, such as cash price, lower cost
clinically appropriate alternatives, whether or not they are
covered under the covered individual's plan, patient
assistance programs, and support programs, and the cost
available at the patient's pharmacy of choice.
(g) A pharmacy benefit manager shall not, except as may be
required by law, interfere with, prevent, or materially
discourage access, exchange, or use of the data as required,
which may include charging fees or not responding to a request

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for such data in a reasonable time frame; nor penalize a health
care provider or professional for disclosing such information
to a covered individual or legally prescribing, administering,
or ordering a clinically appropriate or lower cost
alternative.
(h) Nothing in this Section shall be construed to limit
access to the most up-to-date patient-specific eligibility or
patient-specific prescription cost and benefit data by the
pharmacy benefit manager.
(i) Nothing in this Section shall interfere with patient
choice and a health care professional's ability to convey the
full range of prescription drug cost options to a patient. A
pharmacy benefit manager shall not restrict a health care
professional from communicating prescription cost options to
the patient.
(j) No real-time benefit tool shall require a patient to
use specific plan-preferred drugs or pharmacies.