SB1465 EngrossedLRB099 07911 KTG 28051 b

1    AN ACT concerning public aid.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Public Aid Code is amended by
5adding Section 5-5.12b as follows:
 
6    (305 ILCS 5/5-5.12b new)
7    Sec. 5-5.12b. Interferon-free therapy; prior approval.
8    (a) Prior approval by the Department to administer to a
9recipient of medical assistance any interferon-free therapy
10for the treatment of the hepatitis C virus shall be limited to
11the following criteria:
12        (1) The recipient must be 18 years of age.
13        (2) The recipient must have a diagnosis of chronic
14    hepatitis C infection, genotype 1, 2, 3, or 4, confirmed by
15    stage 2 fibrosis.
16        (3) The recipient may not have been previously denied a
17    prescription for any interferon-free therapy for the
18    treatment of the hepatitis C virus.
19        (4) The recipient may not have end-stage renal disease
20    requiring dialysis.
21        (5) The recipient must have sufficient kidney function
22    as defined by the Department by rule.
23        (6) The recipient may not have evidence of a known and

 

 

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1    incurable disease, with a life expectancy of less than 12
2    months.
3        (7) The recipient may not be receiving hospice care.
4        (8) The recipient may not be taking another treatment
5    that is harmful to take in combination with any
6    interferon-free therapy for the treatment of the hepatitis
7    C virus.
8        (9) The recipient may not have abused a controlled
9    substance within the past 6 months.
10        (10) The recipient must take a drug test no more than
11    15 days prior to submission of the prior approval request.
12    (b) The Department may not use the following criteria as a
13basis for requiring prior approval to administer to a recipient
14of medical assistance any interferon-free therapy for the
15treatment of the hepatitis C virus:
16        (1) The fact that the recipient or any female partner
17    of the recipient is pregnant.
18        (2) The recipient's mental capacity or any
19    determination related to the recipient's ability to make
20    appropriate decisions about the interferon-free therapy
21    treatment or to comply with related instructions.
22        (3) Any evidence or known diagnosis of malignancy of
23    any body organ.
24        (4) The fact that the recipient is receiving or has
25    received chemotherapy or radiation therapy.
26        (5) The fact that the recipient was previously

 

 

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1    administered an interferon-free therapy for the treatment
2    of the hepatitis C virus.
3    (c) A prescriber of any interferon-free therapy for the
4treatment of the hepatitis C virus to a recipient of medical
5assistance shall be one of the following:
6        (1) A gastroenterologist or physician practicing in a
7    relevant sub-specialty.
8        (2) An infectious disease specialist.
9        (3) Any physician licensed to practice medicine in all
10    its branches with a current license who has received a
11    written consultation report from a board-certified
12    gastroenterologist or specialist in a relevant
13    sub-specialty or from an infectious disease specialist. A
14    formal request for prior approval to administer to a
15    medical assistance recipient any interferon-free therapy
16    for the treatment of the hepatitis C virus shall not be
17    submitted to the Department without a written consultation
18    report as provided in this paragraph.
19    (d) The prescriber must submit lab results to the
20Department before the treatment begins, at the end of therapy,
21and 12 weeks after the treatment.
22    (e) The Department shall establish an appeals process for
23recipients who either fail to meet the criteria established in
24subsection (a) but who demonstrate a reasonable consideration
25for continuing treatment, or who received a positive drug test
26within 15 days of the submission of the prior approval request.

 

 

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1The Department shall review cases involving recipients who
2received a positive drug test and who have documentation of a
3drug interaction that would indicate a positive reading from a
4urine test or other drug test.
5    (f) The Department shall pay managed care entities a
6monthly non-capitated rate for any interferon-free therapy for
7the treatment of the hepatitis C virus that is prescribed to a
8recipient of medical assistance. The Department may consider
9the fee-for-service cost of the prescription, the cost
10differential of alternative treatments, and the utilization of
11the drug being prescribed in the development of that rate.
 
12    Section 99. Effective date. This Act takes effect upon
13becoming law.