093_HB2449eng

 
HB2449 Engrossed                     LRB093 03277 DRJ 08378 b

 1        AN ACT in relation to health.

 2        Be  it  enacted  by  the People of the State of Illinois,
 3    represented in the General Assembly:

 4        Section 1.  Short title. This Act may  be  cited  as  the
 5    Mental Health Drug Open Access Authorization Act.

 6        Section 5.  Legislative findings; purpose.
 7        (a)  The General Assembly finds as follows:
 8             (1)  Recipients  of  medical  assistance  under  the
 9        Illinois  Public  Aid  Code  are  often  the State's most
10        disadvantaged   citizens,   burdened   with   significant
11        medical, financial, and social  needs.  Those  recipients
12        benefit  from  an integrated approach to health care with
13        open  and  continuous  access   to   physician-prescribed
14        medications.
15             (2)  Mental  health  patients,  including,  but  not
16        limited to, patients with severe mental illnesses such as
17        schizophrenia,    bipolar    disorder   (manic-depressive
18        illness), or depression,  require  individually  tailored
19        treatments  determined by an appropriately trained health
20        care provider.
21             (3)  Medications for  mental  illness  are  not  the
22        same;  medications  can  vary greatly in effectiveness in
23        treating specific symptoms or disorders or in their  side
24        effects. Patient needs vary greatly, and not all patients
25        respond in the same way to a given treatment.
26             (4)  There  is  ample  evidence that new medications
27        offer therapeutic advantages over older medications  when
28        used within evidence-based clinical practice.
29             (5)  The   determination  of  the  most  appropriate
30        medication for a particular patient with a mental illness
31        should be made on the  basis  of  patient  acceptability,
 
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 1        prior  individual  drug  response, individual side-effect
 2        profile, and concomitant pharmacotherapies; and, finally,
 3        where  multiple  agents   are   equally   documented   as
 4        clinically effective, the final evaluation will be price.
 5             (6)  As  a  member  of  the direct caregiver team, a
 6        patient's physician should determine the most appropriate
 7        treatment that falls within the scope  of  evidence-based
 8        clinical  practice.   As a member of the direct caregiver
 9        team, a patient's pharmacist should apply the  principles
10        of  pharmaceutical care to ensure patient safety relative
11        to potential drug-drug, drug-food,  and  drug-preexisting
12        medical abnormality interactions.
13        (b)  The purpose of this Act is to ensure that recipients
14    of medical assistance under the Illinois Public Aid Code, and
15    other  similarly  situated  patients,  who need treatment for
16    mental  illness  have  open  and  continuous  access  to  the
17    medications  deemed  appropriate  by  their  physicians   and
18    supported by evidence-based clinical practice.

19        Section 10.  Definitions. In this Act:
20        "Cross-indication"  means  that  a  drug  is  used  for a
21    purpose generally held to  be  reasonable,  appropriate,  and
22    within  the  scope of evidence-based clinical practice as set
23    forth in peer-reviewed literature (not case reports).
24        "Department" means the following:
25             (1)  In the case of the Children's Health  Insurance
26        Program under the Children's Health Insurance Program Act
27        or  the  medial  assistance  program  under  the Illinois
28        Public Aid Code: the Department of Public Aid.
29             (2)  In the case of the  program  of  pharmaceutical
30        assistance under the Senior Citizens and Disabled Persons
31        Property  Tax  Relief  and Pharmaceutical Assistance Act:
32        the Department of Revenue.
33             (3)  In the case of  any  other  State  prescription
 
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 1        drug   assistance   program:   the   State   agency  that
 2        administers that program.
 3        "Mental illness" has the meaning ascribed to that term in
 4    the most recent edition of  the  Diagnostic  and  Statistical
 5    Manual   of  Mental  Disorders,  published  by  the  American
 6    Psychiatric Association.
 7        "Prior authorization" means  a  procedure  by  which  the
 8    prescriber  or  dispenser  of  a  drug  must  verify with the
 9    Department or its contractor that the proposed medical use of
10    that drug for a  patient  meets  predetermined  criteria  for
11    coverage under a program described in Section 15.

12        Section  15.  Affected  programs. This Act applies to the
13    following programs:
14             (1)  The Children's Health Insurance  Program  under
15        the Children's Health Insurance Program Act.
16             (2)  The  medial  assistance program under Article V
17        of the Illinois Public  Aid  Code,  as  well  as  medical
18        assistance  provided  to recipients of General Assistance
19        under Article VI of that Code.
20             (3)  The program of pharmaceutical assistance  under
21        the  Senior  Citizens  and  Disabled Persons Property Tax
22        Relief and Pharmaceutical Assistance Act.
23             (4)  Any other State  prescription  drug  assistance
24        program.

25        Section  20.  Prior  authorization of mental health drugs
26    prohibited.
27        (a)  The Department may not use or require the use  of  a
28    prior   authorization   procedure   in  connection  with  the
29    dispensing of a prescription drug, or reimbursement  for  the
30    dispensing  of  a  drug,  that  meets either of the following
31    criteria:
32             (1)  According to the most recent  version  of  AHFS
 
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 1        Drug  Information,  published  by the American Society of
 2        Health-System  Pharmacists,  or  the   Physician's   Desk
 3        Reference, the drug is:
 4                  (A)  classified      as     an     antianxiety,
 5             antidepressant,  or  antipsychotic  central  nervous
 6             system drug; or
 7                  (B)  cross-indicated  for  a  central   nervous
 8             system drug classification.
 9             (2)  The  drug  is  prescribed  for the treatment of
10        mental illness.
11        (b)  Nothing   in   this    Section    precludes    prior
12    authorization   requirements   for   dosages   of  prescribed
13    medications that exceed the maximum dosage established by the
14    federal Food and Drug Administration  where  clinical  safety
15    and efficacy have been established.
16        (c)  Notwithstanding   subdivision   (a)(1)(B)   of  this
17    Section, even though a cross-indicated use is not included in
18    the federal Food and  Drug  Administration's  approved  label
19    indications  for the drug, dosages may not exceed the maximum
20    dosage established by the Food and Drug Administration  where
21    clinical safety and efficacy have been established.
22        (d)  In    compliance    with    Health    Care   Finance
23    Administration guidelines, a functional Drug Use Review (DUR)
24    activity  shall  review  clinical  outcomes  and,  based   on
25    evidence-based clinical practices, intervene where clinically
26    appropriate  to  ensure the health and safety of the patients
27    receiving  health  benefits  coverage  under  the  Children's
28    Health  Insurance  Program  Act,  medical  assistance   under
29    Article   V   or   VI   of  the  Illinois  Public  Aid  Code,
30    pharmaceutical  assistance  under  the  Senior  Citizens  and
31    Disabled  Persons  Property  Tax  Relief  and  Pharmaceutical
32    Assistance  Act,  or   benefits   under   any   other   State
33    prescription drug assistance program.
 
HB2449 Engrossed            -5-      LRB093 03277 DRJ 08378 b
 1        Section  90.  The Children's Health Insurance Program Act
 2    is amended by adding Section 27 as follows:

 3        (215 ILCS 106/27 new)
 4        Sec. 27.  Prior authorization  of  mental  health  drugs;
 5    other restrictions.
 6        (a)  Health   benefits   coverage  provided  to  eligible
 7    children under this Act is subject to the Mental Health  Drug
 8    Open  Access  Authorization Act, except where the dosage of a
 9    prescribed drug exceeds the maximum dosage established by the
10    federal  Food  and  Drug  Administration  where  safety   and
11    clinical efficacy have been established.
12        (b)  Nothing  in  this  Section  shall  be  construed  to
13    prohibit the Department from implementing restrictions, other
14    than  prior  authorization requirements, as necessary for the
15    purpose of ensuring the appropriate  use  of  medications  by
16    program  beneficiaries. Such restrictions include limitations
17    on quantity, prescribing protocols and guidelines, and  other
18    restrictions that are supported by evidence-based medicine.

19        Section  93.  The  Illinois Public Aid Code is amended by
20    changing Sections 5-5.12 and 6-11 as follows:

21        (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
22        Sec. 5-5.12.  Pharmacy payments.
23        (a)  Every  request   submitted   by   a   pharmacy   for
24    reimbursement  under  this  Article  for  prescription  drugs
25    provided  to  a  recipient  of  aid  under this Article shall
26    include  the  name  of  the  prescriber  or   an   acceptable
27    identification number as established by the Department.
28        (b)  Pharmacies  providing  prescription drugs under this
29    Article shall be reimbursed at a rate which shall  include  a
30    professional  dispensing  fee  as  determined by the Illinois
31    Department,  plus  the  current  acquisition  cost   of   the
 
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 1    prescription  drug  dispensed.  The Illinois Department shall
 2    update its  information  on  the  acquisition  costs  of  all
 3    prescription  drugs  no  less  frequently than every 30 days.
 4    However,  the  Illinois  Department  may  set  the  rate   of
 5    reimbursement  for  the  acquisition  cost,  by  rule,  at  a
 6    percentage of the current average wholesale acquisition cost.
 7        (c)  Reimbursement  under  this  Article for prescription
 8    drugs shall be limited  to  reimbursement  for  4  brand-name
 9    prescription  drugs  per  patient per month.  This subsection
10    applies only if (i) the brand-name drug  was  not  prescribed
11    for  an  acute  or urgent condition, (ii) the brand-name drug
12    was  not  prescribed  for  Alzheimer's  disease,   arthritis,
13    diabetes, HIV/AIDS, a mental health condition, or respiratory
14    disease,  and  (iii)  a  therapeutically  equivalent  generic
15    medication  has  been  approved  by the federal Food and Drug
16    Administration.
17        (d)  The Department shall  not  impose  requirements  for
18    prior   approval   based   on   a  preferred  drug  list  for
19    anti-retroviral or any atypical antipsychotics,  conventional
20    antipsychotics,  or anticonvulsants used for the treatment of
21    serious mental illnesses until 30 days after it has conducted
22    a study of the impact of such requirements  on  patient  care
23    and  submitted  a  report  to  the  Speaker  of  the House of
24    Representatives and the President of the Senate.  In the case
25    of a conflict between this subsection and the  Mental  Health
26    Drug  Open  Access  Authorization Act, the Mental Health Drug
27    Open Access Authorization  Act  controls,  except  where  the
28    dosage  of  a  prescribed  drug  exceeds  the  maximum dosage
29    established by the federal Food and Drug Administration where
30    safety and clinical efficacy have been  established.  Nothing
31    in  the  changes  made  by  this  amendatory  Act of the 93rd
32    General  Assembly  shall  be  construed   to   prohibit   the
33    Department  from  implementing restrictions, other than prior
34    authorization requirements, as necessary for the  purpose  of
 
HB2449 Engrossed            -7-      LRB093 03277 DRJ 08378 b
 1    ensuring  the appropriate use of medications by recipients of
 2    medical assistance  under  this  Article.  Such  restrictions
 3    include  limitations  on  quantity, prescribing protocols and
 4    guidelines, and other  restrictions  that  are  supported  by
 5    evidence-based medicine.
 6    (Source:  P.A.  92-597,  eff.  6-28-02; 92-825, eff. 8-21-02;
 7    revised 9-19-02.)

 8        (305 ILCS 5/6-11) (from Ch. 23, par. 6-11)
 9        Sec. 6-11.  State funded General Assistance.
10        (a)  Effective July 1, 1992,  all  State  funded  General
11    Assistance  and related medical benefits shall be governed by
12    this Section.  Other parts of this Code or other laws related
13    to General Assistance shall remain in effect  to  the  extent
14    they do not conflict with the provisions of this Section.  If
15    any  other  part  of  this  Code  or other laws of this State
16    conflict with the provisions of this Section, the  provisions
17    of this Section shall control.
18        (b)  State  funded  General Assistance shall consist of 2
19    separate programs.  One program shall be for adults  with  no
20    children and shall be known as State Transitional Assistance.
21    The other program shall be for families with children and for
22    pregnant  women  and  shall  be  known  as  State  Family and
23    Children Assistance.
24        (c) (1)  To be eligible for State Transitional Assistance
25    on or after July 1, 1992, an individual  must  be  ineligible
26    for  assistance under any other Article of this Code, must be
27    determined  chronically  needy,  and  must  be  one  of   the
28    following:
29             (A)  age 18 or over or
30             (B)  married and living with a spouse, regardless of
31        age.
32        (2)  The  Illinois  Department  or the local governmental
33    unit shall  determine  whether  individuals  are  chronically
 
HB2449 Engrossed            -8-      LRB093 03277 DRJ 08378 b
 1    needy as follows:
 2             (A)  Individuals  who  have applied for Supplemental
 3        Security Income (SSI) and  are  awaiting  a  decision  on
 4        eligibility  for  SSI  who are determined disabled by the
 5        Illinois Department  using  the  SSI  standard  shall  be
 6        considered  chronically  needy,  except  that individuals
 7        whose disability is based solely on substance  addictions
 8        (drug  abuse  and  alcoholism) and whose disability would
 9        cease were their addictions to end shall be eligible only
10        for medical assistance and shall not be eligible for cash
11        assistance  under  the  State   Transitional   Assistance
12        program.
13             (B)  If  an  individual has been denied SSI due to a
14        finding of "not disabled" (either at  the  Administrative
15        Law  Judge  level  or  above, or at a lower level if that
16        determination was not appealed), the Illinois  Department
17        shall  adopt that finding and the individual shall not be
18        eligible for State Transitional Assistance or any related
19        medical  benefits.   Such  an  individual  may   not   be
20        determined  disabled  by  the  Illinois  Department for a
21        period of 12 months, unless  the  individual  shows  that
22        there has been a substantial change in his or her medical
23        condition  or that there has been a substantial change in
24        other factors, such as age or work experience, that might
25        change the determination of disability.
26             (C)  The Illinois Department, by rule,  may  specify
27        other  categories  of  individuals  as chronically needy;
28        nothing in this Section,  however,  shall  be  deemed  to
29        require the inclusion of any specific category other than
30        as specified in paragraphs (A) and (B).
31        (3)  For  individuals  in  State Transitional Assistance,
32    medical assistance shall be provided in an amount and  nature
33    determined  by the Illinois Department of Public Aid by rule.
34    The amount and nature of medical assistance provided need not
 
HB2449 Engrossed            -9-      LRB093 03277 DRJ 08378 b
 1    be  the  same  as  that  provided  under  paragraph  (4)   of
 2    subsection (d) of this Section, and nothing in this paragraph
 3    (3)  shall  be  construed  to  require  the  coverage  of any
 4    particular medical  service.  In  addition,  the  amount  and
 5    nature  of  medical  assistance provided may be different for
 6    different categories of  individuals  determined  chronically
 7    needy.
 8        (4)  The  Illinois  Department  shall determine, by rule,
 9    those assistance recipients under Article  VI  who  shall  be
10    subject   to  employment,  training,  or  education  programs
11    including Earnfare, the content of those  programs,  and  the
12    penalties for failure to cooperate in those programs.
13        (5)  The  Illinois  Department  shall, by rule, establish
14    further eligibility requirements, including but  not  limited
15    to residence, need, and the level of payments.
16        (d) (1)  To  be  eligible  for  State Family and Children
17    Assistance, a family unit must be ineligible  for  assistance
18    under any other Article of this Code and must contain a child
19    who is:
20             (A)  under age 18 or
21             (B)  age  18  and a full-time student in a secondary
22        school or the equivalent level of vocational or technical
23        training, and who may reasonably be expected to  complete
24        the program before reaching age 19.
25        Those  children  shall  be  eligible for State Family and
26    Children Assistance.
27        (2)  The natural or adoptive parents of the child  living
28    in  the  same  household may be eligible for State Family and
29    Children Assistance.
30        (3)  A pregnant woman whose pregnancy has  been  verified
31    shall be eligible for income maintenance assistance under the
32    State Family and Children Assistance program.
33        (4)  The amount and nature of medical assistance provided
34    under  the State Family and Children Assistance program shall
 
HB2449 Engrossed            -10-     LRB093 03277 DRJ 08378 b
 1    be determined by the Illinois Department  of  Public  Aid  by
 2    rule.  The  amount  and nature of medical assistance provided
 3    need not be the same as that provided under paragraph (3)  of
 4    subsection (c) of this Section, and nothing in this paragraph
 5    (4)  shall  be  construed  to  require  the  coverage  of any
 6    particular medical service.
 7        (5)  The Illinois Department shall,  by  rule,  establish
 8    further  eligibility  requirements, including but not limited
 9    to residence, need, and the level of payments.
10        (d-5)  Medical assistance benefits provided  to  eligible
11    recipients  under  this  Section  are  subject  to the Mental
12    Health Drug Open Access Authorization Act.  Nothing  in  this
13    subsection  shall  be construed to prohibit the Department of
14    Public Aid from implementing restrictions, other  than  prior
15    authorization  requirements,  as necessary for the purpose of
16    ensuring the appropriate use of medications by recipients  of
17    medical  assistance  under  this  Section.  Such restrictions
18    include limitations on quantity,  prescribing  protocols  and
19    guidelines,  and  other  restrictions  that  are supported by
20    evidence-based medicine.
21        (e)  A  local   governmental   unit   that   chooses   to
22    participate  in  a  General  Assistance  program  under  this
23    Section  shall  provide  funding  in  accordance with Section
24    12-21.13 of  this  Act.  Local  governmental  funds  used  to
25    qualify  for  State  funding may only be expended for clients
26    eligible for assistance under this Section 6-11  and  related
27    administrative expenses.
28        (f)  In  order  to  qualify  for State funding under this
29    Section, a local governmental unit shall be  subject  to  the
30    supervision  and  the  rules  and regulations of the Illinois
31    Department.
32        (g)  Notwithstanding any other provision  in  this  Code,
33    the  Illinois  Department  is  authorized  to  reduce payment
34    levels used to determine cash grants provided  to  recipients
 
HB2449 Engrossed            -11-     LRB093 03277 DRJ 08378 b
 1    of  State Transitional Assistance at any time within a Fiscal
 2    Year  in  order  to  ensure  that  cash  benefits  for  State
 3    Transitional   Assistance   do   not   exceed   the   amounts
 4    appropriated for those  cash  benefits.  Changes  in  payment
 5    levels  may  be  accomplished by emergency rule under Section
 6    5-45 of the Illinois  Administrative  Procedure  Act,  except
 7    that the limitation on the number of emergency rules that may
 8    be  adopted  in  a  24-month  period  shall not apply and the
 9    provisions of  Sections  5-115  and  5-125  of  the  Illinois
10    Administrative Procedure Act shall not apply.  This provision
11    shall  also  be applicable to any reduction in payment levels
12    made upon implementation of this amendatory Act of 1995.
13    (Source: P.A. 92-111, eff. 1-1-02.)

14        Section 95.  The Senior  Citizens  and  Disabled  Persons
15    Property  Tax  Relief  and  Pharmaceutical  Assistance Act is
16    amended by changing Section 4 as follows:

17        (320 ILCS 25/4) (from Ch. 67 1/2, par. 404)
18        Sec. 4.  Amount of Grant.
19        (a)  In general.  Any individual 65 years or older or any
20    individual who will become 65 years old during  the  calendar
21    year  in  which a claim is filed, and any surviving spouse of
22    such a claimant, who at the time of  death  received  or  was
23    entitled  to  receive a grant pursuant to this Section, which
24    surviving spouse will become 65 years of age  within  the  24
25    months  immediately  following the death of such claimant and
26    which surviving spouse but for his or her  age  is  otherwise
27    qualified  to  receive  a grant pursuant to this Section, and
28    any disabled person whose annual  household  income  is  less
29    than $14,000 for grant years before the 1998 grant year, less
30    than $16,000 for the 1998 and 1999 grant years, and less than
31    (i)  $21,218  for  a  household  containing  one person, (ii)
32    $28,480 for  a  household  containing  2  persons,  or  (iii)
 
HB2449 Engrossed            -12-     LRB093 03277 DRJ 08378 b
 1    $35,740  for a household containing 3 or more persons for the
 2    2000 grant year and thereafter and whose household is  liable
 3    for  payment  of  property  taxes  accrued  or  has paid rent
 4    constituting property taxes accrued and is domiciled in  this
 5    State  at  the  time  he  or  she  files  his or her claim is
 6    entitled to claim a grant under this  Act.  With  respect  to
 7    claims  filed  by  individuals  who  will become 65 years old
 8    during the calendar year in  which  a  claim  is  filed,  the
 9    amount of any grant to which that household is entitled shall
10    be  an  amount  equal  to  1/12  of  the  amount to which the
11    claimant would otherwise be  entitled  as  provided  in  this
12    Section,  multiplied  by  the  number  of months in which the
13    claimant was 65 in the calendar year in which  the  claim  is
14    filed.
15        (b)  Limitation.    Except   as   otherwise  provided  in
16    subsections (a) and (f) of this Section, the  maximum  amount
17    of  grant which a claimant is entitled to claim is the amount
18    by which the  property  taxes  accrued  which  were  paid  or
19    payable   during   the   last  preceding  tax  year  or  rent
20    constituting  property  taxes  accrued  upon  the  claimant's
21    residence for the last preceding taxable year exceeds 3  1/2%
22    of  the  claimant's  household income for that year but in no
23    event is the grant to exceed (i) $700 less 4.5% of  household
24    income  for  that  year  for those with a household income of
25    $14,000 or less or (ii) $70 if household income for that year
26    is more than $14,000.
27        (c)  Public aid recipients.  If household income  in  one
28    or  more  months  during  a  year includes cash assistance in
29    excess of $55 per month from the Department of Public Aid  or
30    the  Department of Human Services (acting as successor to the
31    Department of  Public  Aid  under  the  Department  of  Human
32    Services  Act) which was determined under regulations of that
33    Department on a measure of need that  included  an  allowance
34    for  actual  rent  or property taxes paid by the recipient of
 
HB2449 Engrossed            -13-     LRB093 03277 DRJ 08378 b
 1    that assistance, the amount of grant to which that  household
 2    is  entitled, except as otherwise provided in subsection (a),
 3    shall be the product of (1) the maximum  amount  computed  as
 4    specified in subsection (b) of this Section and (2) the ratio
 5    of  the  number  of  months in which household income did not
 6    include such cash assistance over $55 to the  number  twelve.
 7    If household income did not include such cash assistance over
 8    $55  for  any months during the year, the amount of the grant
 9    to which the household  is  entitled  shall  be  the  maximum
10    amount  computed  as  specified  in  subsection  (b)  of this
11    Section.   For  purposes  of  this   paragraph   (c),   "cash
12    assistance"  does  not  include any amount received under the
13    federal Supplemental Security Income (SSI) program.
14        (d)  Joint ownership.  If title to the residence is  held
15    jointly  by the claimant with a person who is not a member of
16    his or her household, the amount of  property  taxes  accrued
17    used  in  computing the amount of grant to which he or she is
18    entitled shall be  the  same  percentage  of  property  taxes
19    accrued  as  is  the  percentage  of  ownership  held  by the
20    claimant in the residence.
21        (e)  More than one residence.  If a claimant has occupied
22    more than one residence in the taxable year, he  or  she  may
23    claim  only  one  residence  for any part of a month.  In the
24    case of property taxes accrued, he or she shall prorate  1/12
25    of  the  total property taxes accrued on his or her residence
26    to each  month  that  he  or  she  owned  and  occupied  that
27    residence;  and,  in  the  case of rent constituting property
28    taxes accrued, shall prorate each month's  rent  payments  to
29    the residence actually occupied during that month.
30        (f)  There   is   hereby   established   a   program   of
31    pharmaceutical  assistance  to  the  aged  and disabled which
32    shall be administered by the Department  in  accordance  with
33    this Act, to consist of payments to authorized pharmacies, on
34    behalf  of  beneficiaries  of the program, for the reasonable
 
HB2449 Engrossed            -14-     LRB093 03277 DRJ 08378 b
 1    costs of covered prescription drugs.   Each  beneficiary  who
 2    pays  $5  for  an identification card shall pay no additional
 3    prescription costs.  Each beneficiary who  pays  $25  for  an
 4    identification  card  shall  pay  $3  per  prescription.   In
 5    addition,  after  a  beneficiary  receives $2,000 in benefits
 6    during a State fiscal year, that beneficiary  shall  also  be
 7    charged  20%  of  the  cost  of  each  prescription for which
 8    payments are made by the program during the remainder of  the
 9    fiscal  year.   To  become a beneficiary under this program a
10    person must: (1) be (i) 65 years of age or older, or (ii) the
11    surviving spouse of such a claimant, who at the time of death
12    received or was entitled to receive benefits pursuant to this
13    subsection, which surviving spouse will become  65  years  of
14    age  within  the 24 months immediately following the death of
15    such claimant and which surviving spouse but for his  or  her
16    age  is  otherwise  qualified to receive benefits pursuant to
17    this subsection, or (iii) disabled, and (2) be  domiciled  in
18    this  State at the time he or she files his or her claim, and
19    (3) have a maximum household income of less than $14,000  for
20    grant years before the 1998 grant year, less than $16,000 for
21    the  1998 and 1999 grant years, and less than (i) $21,218 for
22    a  household  containing  one  person,  (ii)  $28,480  for  a
23    household containing  2  persons,  or  (iii)  $35,740  for  a
24    household  containing  3 more persons for the 2000 grant year
25    and thereafter.  In addition, each eligible person  must  (1)
26    obtain an identification card from the Department, (2) at the
27    time  the card is obtained, sign a statement assigning to the
28    State of Illinois benefits which  may  be  otherwise  claimed
29    under  any  private  insurance  plans,  and  (3)  present the
30    identification card to the dispensing pharmacist.
31        Whenever a generic equivalent for a covered  prescription
32    drug  is  available,  the Department shall reimburse only for
33    the reasonable costs of  the  generic  equivalent,  less  the
34    co-pay  established  in  this Section, unless (i) the covered
 
HB2449 Engrossed            -15-     LRB093 03277 DRJ 08378 b
 1    prescription drug contains one or more ingredients defined as
 2    a narrow therapeutic index drug at 21 CFR  320.33,  (ii)  the
 3    prescriber  indicates  on the face of the prescription "brand
 4    medically necessary", and (iii) the prescriber specifies that
 5    a substitution  is  not  permitted.   When  issuing  an  oral
 6    prescription for covered prescription medication described in
 7    item  (i)  of  this paragraph, the prescriber shall stipulate
 8    "brand medically necessary" and that a  substitution  is  not
 9    permitted.    If   the  covered  prescription  drug  and  its
10    authorizing prescription do  not  meet  the  criteria  listed
11    above,   the   beneficiary   may   purchase  the  non-generic
12    equivalent of the covered prescription  drug  by  paying  the
13    difference  between the generic cost and the non-generic cost
14    plus the beneficiary co-pay.
15        Pharmaceutical assistance benefits provided  to  eligible
16    persons  under this Act are subject to the Mental Health Drug
17    Open Access Authorization Act.  Nothing in the  changes  made
18    by  this amendatory Act of the 93rd General Assembly shall be
19    construed  to  prohibit  the  Department  of   Revenue   from
20    implementing  restrictions,  other  than  prior authorization
21    requirements, as necessary for the purpose  of  ensuring  the
22    appropriate    use    of   medications   by   recipients   of
23    pharmaceutical assistance under this Act.  Such  restrictions
24    include  limitations  on  quantity, prescribing protocols and
25    guidelines, and other  restrictions  that  are  supported  by
26    evidence-based medicine.
27        Any   person   otherwise   eligible   for  pharmaceutical
28    assistance under this Act whose covered drugs are covered  by
29    any  public  program for assistance in purchasing any covered
30    prescription drugs shall be ineligible for  assistance  under
31    this  Act  to the extent such costs are covered by such other
32    plan.
33        The  fee  to  be  charged  by  the  Department  for   the
34    identification  card  shall  be equal to $5 per coverage year
 
HB2449 Engrossed            -16-     LRB093 03277 DRJ 08378 b
 1    for persons below the official poverty line as defined by the
 2    United States Department of Health and Human Services and $25
 3    per coverage year for all other persons.
 4        In the event that 2 or more persons are eligible for  any
 5    benefit   under  this  Act,  and  are  members  of  the  same
 6    household,  (1)  each  such  person  shall  be  entitled   to
 7    participate   in   the   pharmaceutical  assistance  program,
 8    provided that he or she meets all other requirements  imposed
 9    by  this  subsection  and  (2)  each  participating household
10    member contributes the fee required for that  person  by  the
11    preceding   paragraph   for   the  purpose  of  obtaining  an
12    identification card.
13    (Source: P.A. 91-357,  eff.  7-29-99;  91-699,  eff.  1-1-01;
14    92-131,  eff.  7-23-01;  92-519,  eff.  1-1-02;  92-651, eff.
15    7-11-02.)

16        Section 99.  Effective date.  This Act takes effect  upon
17    becoming law.