Rep. Mary E. Flowers

Filed: 3/27/2014

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 4018

2    AMENDMENT NO. ______. Amend House Bill 4018 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-5.12 as follows:
 
6    (305 ILCS 5/5-5.12)  (from Ch. 23, par. 5-5.12)
7    Sec. 5-5.12. Pharmacy payments.
8    (a) Every request submitted by a pharmacy for reimbursement
9under this Article for prescription drugs provided to a
10recipient of aid under this Article shall include the name of
11the prescriber or an acceptable identification number as
12established by the Department.
13    (b) Pharmacies providing prescription drugs under this
14Article shall be reimbursed at a rate which shall include a
15professional dispensing fee as determined by the Illinois
16Department, plus the current acquisition cost of the

 

 

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1prescription drug dispensed. The Illinois Department shall
2update its information on the acquisition costs of all
3prescription drugs no less frequently than every 30 days.
4However, the Illinois Department may set the rate of
5reimbursement for the acquisition cost, by rule, at a
6percentage of the current average wholesale acquisition cost.
7    (c) (Blank).
8    (d) The Department shall review utilization of narcotic
9medications in the medical assistance program and impose
10utilization controls that protect against abuse.
11    (e) When making determinations as to which drugs shall be
12on a prior approval list, the Department shall include as part
13of the analysis for this determination, the degree to which a
14drug may affect individuals in different ways based on factors
15including the gender of the person taking the medication.
16    (f) The Department shall cooperate with the Department of
17Public Health and the Department of Human Services Division of
18Mental Health in identifying psychotropic medications that,
19when given in a particular form, manner, duration, or frequency
20(including "as needed") in a dosage, or in conjunction with
21other psychotropic medications to a nursing home resident or to
22a resident of a facility licensed under the ID/DD Community
23Care Act, may constitute a chemical restraint or an
24"unnecessary drug" as defined by the Nursing Home Care Act or
25Titles XVIII and XIX of the Social Security Act and the
26implementing rules and regulations. The Department shall

 

 

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1require prior approval for any such medication prescribed for a
2nursing home resident or to a resident of a facility licensed
3under the ID/DD Community Care Act, that appears to be a
4chemical restraint or an unnecessary drug. The Department shall
5consult with the Department of Human Services Division of
6Mental Health in developing a protocol and criteria for
7deciding whether to grant such prior approval.
8    (g) The Department may by rule provide for reimbursement of
9the dispensing of a 90-day supply of a generic or brand name,
10non-narcotic maintenance medication in circumstances where it
11is cost effective.
12    (g-5) On and after July 1, 2012, the Department may require
13the dispensing of drugs to nursing home residents be in a 7-day
14supply or other amount less than a 31-day supply. The
15Department shall pay only one dispensing fee per 31-day supply.
16    (h) Effective July 1, 2011, the Department shall
17discontinue coverage of select over-the-counter drugs,
18including analgesics and cough and cold and allergy
19medications.
20    (h-5) On and after July 1, 2012, the Department shall
21impose utilization controls, including, but not limited to,
22prior approval on specialty drugs, oncolytic drugs, drugs for
23the treatment of HIV or AIDS, immunosuppressant drugs, and
24biological products in order to maximize savings on these
25drugs. The Department may adjust payment methodologies for
26non-pharmacy billed drugs in order to incentivize the selection

 

 

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1of lower-cost drugs. For drugs for the treatment of AIDS, the
2Department shall take into consideration the potential for
3non-adherence by certain populations, and shall develop
4protocols with organizations or providers primarily serving
5those with HIV/AIDS, as long as such measures intend to
6maintain cost neutrality with other utilization management
7controls such as prior approval. For hemophilia, the Department
8shall develop a program of utilization review and control which
9may include, in the discretion of the Department, prior
10approvals. The Department may impose special standards on
11providers that dispense blood factors which shall include, in
12the discretion of the Department, staff training and education;
13patient outreach and education; case management; in-home
14patient assessments; assay management; maintenance of stock;
15emergency dispensing timeframes; data collection and
16reporting; dispensing of supplies related to blood factor
17infusions; cold chain management and packaging practices; care
18coordination; product recalls; and emergency clinical
19consultation. The Department may require patients to receive a
20comprehensive examination annually at an appropriate provider
21in order to be eligible to continue to receive blood factor.
22    (i) On and after July 1, 2012, the Department shall reduce
23any rate of reimbursement for services or other payments or
24alter any methodologies authorized by this Code to reduce any
25rate of reimbursement for services or other payments in
26accordance with Section 5-5e.

 

 

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1    (j) On and after July 1, 2012, the Department shall impose
2limitations on prescription drugs such that the Department
3shall not provide reimbursement for more than 4 prescriptions,
4including 3 brand name prescriptions, for distinct drugs in a
530-day period, unless prior approval is received for all
6prescriptions in excess of the 4-prescription limit. Drugs in
7the following therapeutic classes shall not be subject to prior
8approval as a result of the 4-prescription limit:
9immunosuppressant drugs, oncolytic drugs, and anti-retroviral
10drugs. Anytime a prescribing physician or dispensing
11pharmacist submits a request for prior approval of one or more
12prescriptions in excess of the 4-prescription limit, the
13Department shall pay to the prescribing physician or dispensing
14pharmacist a $20 consultation fee.
15    (k) No medication therapy management program implemented
16by the Department shall be contrary to the provisions of the
17Pharmacy Practice Act.
18    (l) Any provider enrolled with the Department that bills
19the Department for outpatient drugs and is eligible to enroll
20in the federal Drug Pricing Program under Section 340B of the
21federal Public Health Services Act shall enroll in that
22program. No entity participating in the federal Drug Pricing
23Program under Section 340B of the federal Public Health
24Services Act may exclude Medicaid from their participation in
25that program, although the Department may exclude entities
26defined in Section 1905(l)(2)(B) of the Social Security Act

 

 

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1from this requirement.
2(Source: P.A. 97-38, eff. 6-28-11; 97-74, eff. 6-30-11; 97-333,
3eff. 8-12-11; 97-426, eff. 1-1-12; 97-689, eff. 6-14-12;
497-813, eff. 7-13-12; 98-463, eff. 8-16-13.)".