HB5769 EngrossedLRB100 18687 SMS 33918 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by adding
5Section 364.3 as follows:
 
6    (215 ILCS 5/364.3 new)
7    Sec. 364.3. Insurer uniform electronic prior authorization
8form; prescription benefits.
9    (a) As used in this Section, "prescribing provider"
10includes a provider authorized to write a prescription, as
11described in subsection (e) of Section 3 of the Pharmacy
12Practice Act, to treat a medical condition of an insured.
13    (b) Notwithstanding any other provision of law to the
14contrary, on and after July 1, 2020, an insurer that provides
15prescription drug benefits shall utilize and accept the uniform
16electronic prior authorization form developed pursuant to
17subsection (c) when requiring prior authorization for
18prescription drug benefits.
19    (c) On or before July 1, 2019, the Department shall develop
20a uniform electronic prior authorization form that shall be
21used by commercial insurers. Notwithstanding any other
22provision of law to the contrary, on and after July 1, 2020,
23every prescribing provider must use the uniform electronic

 

 

HB5769 Engrossed- 2 -LRB100 18687 SMS 33918 b

1prior authorization form to request prior authorization for
2coverage of prescription drug benefits and every insurer shall
3accept the uniform electronic prior authorization form as
4sufficient to request prior authorization for prescription
5drug benefits.
6    (d) The Department shall develop the uniform electronic
7prior authorization form with input from interested parties,
8including, but not limited to, the following individuals
9appointed by the Director: 2 psychiatrists recommended by a
10State organization that represents psychiatrists, 2
11pharmacists recommended by a State organization that
12represents pharmacists, 2 physicians recommended by a State
13organization that represents physicians, 2 family physicians
14recommended by a State organization that represents family
15physicians, 2 pediatricians recommended by a State
16organization that represents pediatricians, and 2
17representatives of the association that represents commercial
18insurers, from at least one public meeting.
19    (e) The Department, in development of the uniform
20electronic prior authorization form, shall take into
21consideration the following:
22        (1) existing prior authorization forms established by
23    the federal Centers for Medicare and Medicaid Services and
24    the Department; and
25        (2) national standards pertaining to electronic prior
26    authorization.

 

 

HB5769 Engrossed- 3 -LRB100 18687 SMS 33918 b

1    (f) If, upon receipt of a completed and accurate electronic
2prior authorization request from a prescribing provider
3pursuant to the submission of a uniform electronic prior
4authorization form, an insurer fails to use or accept the
5uniform electronic prior authorization form or fails to respond
6within 24 hours (if the patient has urgent medication needs) or
7within 72 hours (if the patient has regular medication needs),
8then the prior authorization request shall be deemed to have
9been granted.
 
10    Section 10. The Illinois Public Aid Code is amended by
11adding Section 5-5.12b as follows:
 
12    (305 ILCS 5/5-5.12b new)
13    Sec. 5-5.12b. Managed care organization uniform electronic
14prior authorization form; prescription benefits.
15    (a) As used in this Section, "prescribing provider"
16includes a provider authorized to write a prescription, as
17described in subsection (e) of Section 3 of the Pharmacy
18Practice Act, to treat a medical condition of an insured.
19    (b) Notwithstanding any other provision of law to the
20contrary, on and after July 1, 2020, a managed care
21organization that provides prescription drug benefits shall
22utilize and accept the uniform electronic prior authorization
23form developed pursuant to subsection (c) when requiring prior
24authorization for prescription drug benefits.

 

 

HB5769 Engrossed- 4 -LRB100 18687 SMS 33918 b

1    (c) On or before July 1, 2019, the Department of Healthcare
2and Family Services shall develop a uniform electronic prior
3authorization form that shall be used by managed care
4organizations. Notwithstanding any other provision of law to
5the contrary, on and after July 1, 2020, every prescribing
6provider must use the uniform electronic prior authorization
7form to request prior authorization for coverage of
8prescription drug benefits, and every managed care
9organization shall accept the uniform electronic prior
10authorization form as sufficient to request prior
11authorization for prescription drug benefits.
12    (d) The Department of Healthcare and Family Services shall
13develop the uniform electronic prior authorization form with
14input from interested parties, including, but not limited to,
15the following individuals appointed by the Director of
16Healthcare and Family Services: 2 psychiatrists recommended by
17a State organization that represents psychiatrists, 2
18pharmacists recommended by a State organization that
19represents pharmacists, 2 physicians recommended by a State
20organization that represents physicians, 2 family physicians
21recommended by a State organization that represents family
22physicians, 2 pediatricians recommended by a State
23organization that represents pediatricians, and 2
24representatives of the association that represents managed
25care organizations, from at least one public meeting.
26    (e) The Department of Healthcare and Family Services, in

 

 

HB5769 Engrossed- 5 -LRB100 18687 SMS 33918 b

1development of the uniform electronic prior authorization
2form, shall take into consideration the following:
3        (1) existing prior authorization forms established by
4    the federal Centers for Medicare and Medicaid Services and
5    the Department of Healthcare and Family Services; and
6        (2) national standards pertaining to electronic prior
7    authorization.
8    (f) If, upon receipt of a completed and accurate electronic
9prior authorization request from a prescribing provider
10pursuant to the submission of a uniform electronic prior
11authorization form, a managed care organization fails to use or
12accept the uniform electronic prior authorization form or fails
13to respond within 24 hours, then the prior authorization
14request shall be deemed to have been granted.