98TH GENERAL ASSEMBLY
State of Illinois
2013 and 2014
SB3395

 

Introduced 2/14/2014, by Sen. Linda Holmes

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/356z.22 new

    Amends the Illinois Insurance Code. Provides that a health plan that provides coverage for prescription drugs shall ensure that (1) any required copayment or coinsurance applicable to drugs on a specialty tier does not exceed $100 per month for up to a 30-day supply of any single drug and (2) required copayment or coinsurance for drugs on a specialty tier does not exceed, in the aggregate for those specialty tier covered drugs, $200 per month per enrollee. Provides that a health plan that provides coverage for prescription drugs and utilizes a tiered formulary shall implement an exceptions process that allows enrollees to request an exception to the tiered cost-sharing structure. Makes other changes. Effective January 1, 2015.


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A BILL FOR

 

SB3395LRB098 20278 RPM 55691 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 356z.22 as follows:
 
6    (215 ILCS 5/356z.22 new)
7    Sec. 356z.22. Specialty tier prescription coverage.
8    (a) In this Section:
9    "Coinsurance" means a cost-sharing amount set as a
10percentage of the total cost of a drug.
11    "Copayment" means a cost-sharing amount set as a dollar
12value.
13    "Non-preferred drug" means a drug in a tier designed for
14certain drugs deemed non-preferred and therefore subject to
15higher cost-sharing amounts than preferred drugs.
16    "Preferred drug" means a drug in a tier designed for
17certain drugs deemed preferred and therefore subject to lower
18cost-sharing amounts than non-preferred drugs.
19    "Specialty tier" means a tier of cost sharing designed for
20select specialty drugs that imposes cost-sharing obligations
21that exceed that amount for non-preferred brand-name drugs or
22their equivalent (for brand-name drugs if there is no
23non-preferred brand-name drug category) and such a

 

 

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1cost-sharing amount is based on a coinsurance.
2    "Tiered formulary" means a formulary that provides
3coverage for prescription drugs as part of a health plan for
4which cost sharing, deductibles, or coinsurance obligations
5are determined by category or tier of prescription drugs and
6includes at least 2 different tiers.
7    (b) A health plan that provides coverage for prescription
8drugs shall ensure that:
9        (1) any required copayment or coinsurance applicable
10    to drugs on a specialty tier does not exceed $100 per month
11    for up to a 30-day supply of any single drug; and
12        (2) any required copayment or coinsurance for drugs on
13    a specialty tier does not exceed, in the aggregate for
14    those specialty tier covered drugs, $200 per month per
15    enrollee.
16    (c) A health plan that provides coverage for prescription
17drugs and utilizes a tiered formulary shall implement an
18exceptions process that allows enrollees to request an
19exception to the tiered cost-sharing structure. Under such an
20exception, a non-preferred drug may be covered under the cost
21sharing applicable for preferred drugs if the prescribing
22physician determines that the preferred drug for treatment of
23the same condition either would not be as effective for the
24individual or would have adverse effects for the individual, or
25both. In the event an enrollee is denied a cost-sharing
26exception, the denial shall be considered an adverse event and

 

 

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1shall be subject to the health plan's internal review process.
2    (d) A health plan that provides coverage for prescription
3drugs is prohibited from placing all drugs in a given class on
4a specialty tier.
5    (e) Nothing in this Section shall be construed to require a
6health plan to:
7        (1) provide coverage for any additional drugs not
8    otherwise required by law;
9        (2) implement specific utilization management
10    techniques, such as prior authorization or step therapy; or
11        (3) cease utilization of tiered cost-sharing
12    structures, including those strategies used to incent use
13    of preventive services, disease management, and low-cost
14    treatment options.
15    (f) Nothing in this Section shall be construed to require a
16pharmacist to substitute a drug without the consent of the
17prescribing physician.
18    (g) The Director shall adopt rules outlining the
19enforcement processes for this Section.
 
20    Section 99. Effective date. This Act takes effect January
211, 2015.