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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:
The Illinois Public Aid Code is amended by
adding Section 5-5.12b as follows:
(305 ILCS 5/5-5.12b new)
Interferon-free therapy; prior approval.
Prior approval by the Department to administer to a
recipient of medical assistance any interferon-free therapy
for the treatment of the hepatitis C virus shall be limited to
the following criteria:
(1) The recipient must be 18 years of age.
(2) The recipient must have a diagnosis of chronic
hepatitis C infection, genotype 1, 2, 3, or 4, confirmed by
stage 2 fibrosis.
(3) The recipient may not have been previously denied a
prescription for any interferon-free therapy for the
treatment of the hepatitis C virus.
(4) The recipient may not have end-stage renal disease
(5) The recipient must have sufficient kidney function
as defined by the Department by rule.
(6) The recipient may not have evidence of a known and
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incurable disease, with a life expectancy of less than 12
(7) The recipient may not be receiving hospice care.
(8) The recipient may not be taking another treatment
that is harmful to take in combination with any
interferon-free therapy for the treatment of the hepatitis
(9) The recipient may not have abused a controlled
substance within the past 6 months.
(10) The recipient must take a drug test no more than
15 days prior to submission of the prior approval request.
(b) The Department may not use the following criteria as a
basis for requiring prior approval to administer to a recipient
of medical assistance any interferon-free therapy for the
treatment of the hepatitis C virus:
(1) The fact that the recipient or any female partner
of the recipient is pregnant.
(2) The recipient's mental capacity or any
determination related to the recipient's ability to make
appropriate decisions about the interferon-free therapy
treatment or to comply with related instructions.
(3) Any evidence or known diagnosis of malignancy of
any body organ.
(4) The fact that the recipient is receiving or has
received chemotherapy or radiation therapy.
(5) The fact that the recipient was previously
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administered an interferon-free therapy for the treatment
of the hepatitis C virus.
(c) A prescriber of any interferon-free therapy for the
treatment of the hepatitis C virus to a recipient of medical
assistance shall be one of the following:
(1) A gastroenterologist or physician practicing in a
(2) An infectious disease specialist.
(3) Any physician licensed to practice medicine in all
its branches with a current license who has received a
written consultation report from a board-certified
gastroenterologist or specialist in a relevant
sub-specialty or from an infectious disease specialist. A
formal request for prior approval to administer to a
medical assistance recipient any interferon-free therapy
for the treatment of the hepatitis C virus shall not be
submitted to the Department without a written consultation
report as provided in this paragraph.
(d) The prescriber must submit lab results to the
Department before the treatment begins, at the end of therapy,
and 12 weeks after the treatment.
(e) The Department shall establish an appeals process for
recipients who either fail to meet the criteria established in
subsection (a) but who demonstrate a reasonable consideration
for continuing treatment, or who received a positive drug test
within 15 days of the submission of the prior approval request.
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The Department shall review cases involving recipients who
received a positive drug test and who have documentation of a
drug interaction that would indicate a positive reading from a
urine test or other drug test.
(f) The Department shall pay managed care entities a
monthly non-capitated rate for any interferon-free therapy for
the treatment of the hepatitis C virus that is prescribed to a
recipient of medical assistance. The Department may consider
the fee-for-service cost of the prescription, the cost
differential of alternative treatments, and the utilization of
the drug being prescribed in the development of that rate.
This Act takes effect upon