093_SB1026

 
                                     LRB093 07232 DRJ 07388 b

 1        AN ACT in relation to public aid.

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

 4        Section  5.  The  Illinois  Public Aid Code is amended by
 5    changing  Section  5-5.12  and  adding  Section  5-5.12b   as
 6    follows:

 7        (305 ILCS 5/5-5.12) (from Ch. 23, par. 5-5.12)
 8        Sec. 5-5.12.  Pharmacy payments.
 9        (a)  Every   request   submitted   by   a   pharmacy  for
10    reimbursement  under  this  Article  for  prescription  drugs
11    provided to a recipient  of  aid  under  this  Article  shall
12    include   the   name  of  the  prescriber  or  an  acceptable
13    identification number as established by the Department.
14        (b)  Pharmacies providing prescription drugs  under  this
15    Article  shall  be reimbursed at a rate which shall include a
16    professional dispensing fee as  determined  by  the  Illinois
17    Department,   plus   the  current  acquisition  cost  of  the
18    prescription drug dispensed. The  Illinois  Department  shall
19    update  its  information  on  the  acquisition  costs  of all
20    prescription drugs no less frequently  than  every  30  days.
21    However,   the  Illinois  Department  may  set  the  rate  of
22    reimbursement  for  the  acquisition  cost,  by  rule,  at  a
23    percentage of the current average wholesale acquisition cost.
24        (b-5)  The State's Medicaid  plan  shall  provide  for  a
25    program  of  differential dispensing fees for pharmacies that
26    (i) provide prescriptions for adult care homes under  a  unit
27    dose  system  in accordance with rules and regulations of the
28    State Board of Pharmacy and (ii) participate in the return of
29    unused medications program under this Article V.
30        The State's Medicaid plan shall  include  provisions  for
31    differential  ingredient  cost  reimbursement  of generic and
 
                            -2-      LRB093 07232 DRJ 07388 b
 1    brand name pharmaceuticals.  The  Department  of  Public  Aid
 2    shall  set  the  rates for differential cost reimbursement of
 3    generic and brand name pharmaceuticals by rule.
 4        (c)  Reimbursement under this  Article  for  prescription
 5    drugs  shall  be  limited  to  reimbursement for 4 brand-name
 6    prescription drugs per patient per  month.   This  subsection
 7    applies  only  if  (i) the brand-name drug was not prescribed
 8    for an acute or urgent condition, (ii)  the  brand-name  drug
 9    was   not  prescribed  for  Alzheimer's  disease,  arthritis,
10    diabetes, HIV/AIDS, a mental health condition, or respiratory
11    disease,  and  (iii)  a  therapeutically  equivalent  generic
12    medication has been approved by the  federal  Food  and  Drug
13    Administration.
14        Except   where   a   prescriber  has  personally  written
15    "dispense  as  written"  or  "D.A.W.,"  or  has  signed   the
16    prescriber's  name  on  the  "dispense  as written" signature
17    line, the Department of Public Aid  may  limit  reimbursement
18    for  a  prescription  under the medical assistance program to
19    the multisource generic equivalent drug.
20        No pharmacist participating  in  the  medical  assistance
21    program  shall  be  required  to dispense a prescription-only
22    drug that will not be reimbursed by  the  medical  assistance
23    program.
24        (d)  The  Department  shall  not  impose requirements for
25    prior  approval  based  on  a   preferred   drug   list   for
26    anti-retroviral  or any atypical antipsychotics, conventional
27    antipsychotics, or anticonvulsants used for the treatment  of
28    serious mental illnesses until 30 days after it has conducted
29    a  study  of  the impact of such requirements on patient care
30    and submitted a  report  to  the  Speaker  of  the  House  of
31    Representatives and the President of the Senate.
32        (e)  No  requirements  for  prior  authorization or other
33    restrictions on medications used to  treat  mental  illnesses
34    such as schizophrenia, depression, or bipolar disorder may be
 
                            -3-      LRB093 07232 DRJ 07388 b
 1    imposed on recipients of medical assistance. Medications that
 2    must  be  made  be  available under the State's Medicaid plan
 3    without restriction for persons with mental illnesses include
 4    atypical     antipsychotic     medications,      conventional
 5    antipsychotic medications, and other medications used for the
 6    treatment of mental illnesses.
 7        (f)  A prescription medication prescribed for a recipient
 8    of  medical  assistance  or a person who becomes eligible for
 9    medical assistance shall not be subject  to  any  requirement
10    for  prior  authorization  under  the  State's  Medicaid plan
11    unless  (i)  the  prescription,  including   all   authorized
12    refills,  has expired or (ii) the practitioner who prescribed
13    the medication  for  the  recipient  prescribes  a  different
14    medication.
15    (Source:  P.A.  92-597,  eff.  6-28-02; 92-825, eff. 8-21-02;
16    revised 9-19-02.)

17        (305 ILCS 5/5-5.12b new)
18        Sec. 5-5.12b. Preferred drug formulary.
19        (a)  The  Department  of  Public  Aid  may  establish   a
20    statewide  advisory  committee pursuant to Section 12-4.20 of
21    this Code to advise the Department in the  development  of  a
22    preferred  formulary  listing of drugs covered by the medical
23    assistance program.
24        (b)  The Department shall evaluate drugs and drug classes
25    for inclusion in the State Medicaid preferred drug  formulary
26    based  on  safety,  effectiveness,  and  clinical outcomes of
27    treatments. In addition, the Department shall evaluate  drugs
28    and  drug  classes  to  determine  whether inclusion of those
29    drugs or drug classes in  a  starter-dose  program  would  be
30    clinically  efficacious and cost effective. If the factors of
31    safety, effectiveness,  and  clinical  outcomes  among  drugs
32    being  considered  in  the same class indicate no therapeutic
33    advantage,  then  the  Department  shall  consider  the  cost
 
                            -4-      LRB093 07232 DRJ 07388 b
 1    effectiveness and the net economic impact  of  the  drugs  in
 2    making  recommendations  for  inclusion in the State Medicaid
 3    preferred  drug  formulary.  Drugs  that  do   not   have   a
 4    significant,  clinically  meaningful therapeutic advantage in
 5    terms of safety, effectiveness,  or  clinical  outcomes  over
 6    other drugs in the same class that have been selected for the
 7    preferred  drug  formulary may be excluded from the preferred
 8    drug formulary and may be subject to prior  authorization  in
 9    accordance  with  State  and federal law, except for cases in
10    which, before July  1,  2004,  a  prescriber  has  personally
11    written  "dispense  as written" or "D.A.W." or has signed the
12    prescriber's name on  the  "dispense  as  written"  signature
13    line.
14        (c)  The  Department  shall  consider  the  net  economic
15    impact  of drugs selected or excluded from the preferred drug
16    formulary and may gather information on the costs of specific
17    drugs, rebates, or discounts pursuant to 42  U.S.C.  1396r-8,
18    dispensing  costs,  dosing  requirements,  and utilization of
19    other drugs or other Medicaid health care services.
20        (d)  The Department may accept all  services,  including,
21    but not limited to, disease state management, associated with
22    the   delivery   of   pharmacy  benefits  under  the  medical
23    assistance program having  a  determinable  cost  effect,  in
24    addition  to  the Medicaid prescription drug rebates required
25    pursuant to 42 U.S.C. section 1396r-8.
26        (e)  The  Department  shall  submit  the  State  Medicaid
27    preferred drug  formulary  to  the  drug  utilization  review
28    program  established  under  Section 11-26.1 of this Code for
29    review and policy recommendations.

30        Section 99.  Effective date.  This Act takes effect  upon
31    becoming law.