Sen. Andy Manar

Filed: 5/8/2018





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2    AMENDMENT NO. ______. Amend House Bill 3479, AS AMENDED, by
3inserting at the end of the bill the following:
4    "Section 10. The Illinois Public Aid Code is amended by
5adding Section 5-30.8 as follows:
6    (305 ILCS 5/5-30.8 new)
7    Sec. 5-30.8. Pharmacy reimbursement rates; managed care.
8    (a) As used in this Section:
9    "Actual acquisition cost" means the listed amount for a
10pharmaceutical product on the pharmacy provider's billing
12    "Pharmacy benefits manager" means an entity that
13administers or manages a pharmacy benefits plan or program.
14    (b) The Department shall require a managed care
15organization, including any pharmacy benefits manager, to
16reimburse pharmacy providers equal to the Department's



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1fee-for-service reimbursement rates.
2    (c) The reimbursement rate for prescription medications
3shall include a professional dispensing fee, which shall equal
4the fee-for-service professional dispensing fee utilized by
5the Department.
6    (d) The Department shall require a managed care
7organization, including any pharmacy benefits manager, to
8reimburse pharmacies for patient care services provided by a
9pharmacist at no less than 85% of the fee schedule for
10physician services.
11    (e) Any pharmacy provider may appeal the reimbursement rate
12for prescription medications or patient care services.
13        (1) The Department shall have the authority to require
14    the managed care organization or pharmacy benefits manager
15    to submit information to the Department related to the
16    managed care organization's or pharmacy benefits manager's
17    pricing methodology and rationale.
18        (2) The managed care organization or pharmacy benefits
19    manager must respond to the request for information no
20    later than 7 days after the date upon which the request is
21    made. If the managed care organization or pharmacy benefits
22    manager does not respond to the Department's request within
23    7 days after the date upon which the request is made, the
24    Department shall render a final decision in favor of the
25    pharmacy provider.
26    (f) At no time shall a pharmacy provider that contracts



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1with a managed care organization or pharmacy benefits manager
2be forced to dispense any prescription medication for a
3reimbursement rate below the actual acquisition cost.
4    (g) The contracting of pharmacy providers shall be
5separated from any other group or national pharmacy provider
6contract offered by a pharmacy benefits manager.
7    (h) Medicaid pharmacy provider participation must remain
8voluntary, as under the fee-for-service medical assistance
10    (i) A pharmacy benefits manager shall not require a
11pharmacy provider to participate in a Medicaid managed care
12organization's provider network.
13    (j) A pharmacy provider may decline to participate in a
14contract with a pharmacy benefits manager and remain a
15fee-for-service provider.
16    (k) No later than January 1, 2019, the Auditor General
17shall initiate an audit of Medicaid managed care organizations
18contracted with the Department and pharmacy benefits managers
19contracted with Medicaid managed care organizations to
20determine if their reimbursement methodologies are fair and to
21determine the amount of Medicaid dollars retained by the
22pharmacy benefits managers.
23    Section 99. Effective date. This Section and Section 10
24take effect upon becoming law.".